[Senate Report 115-212]
[From the U.S. Government Publishing Office]
Calendar No. 273
115th Congress } { Report
SENATE
2d Session } { 115-212
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CARING FOR OUR VETERANS ACT OF 2017
_______
March 7, 2018.--Ordered to be printed
_______
Mr. Isakson, from the Committee on Veterans' Affairs,
submitted the following
R E P O R T
[To accompany S. 2193]
[Including cost estimate of the Congressional Budget Office]
The Committee on Veterans' Affairs (hereinafter,
``Committee''), having considered an original bill, S. 2193, to
amend title 38, United States Code (hereinafter, ``U.S.C.''),
to improve health care for veterans, and for other purposes,
having considered the same, reports favorably thereon and
recommends that the bill do pass.
Introduction
On January 12, 2017, Senator Heller introduced S. 113, the
proposed Maximizing Efficiency and Improving Access to
Providers at the Department of Veterans Affairs Act. S. 113
would require the Secretary of Veterans Affairs to carry out a
pilot program to increase the use of medical scribes to
maximize the efficiency of physicians at medical facilities of
the Department of Veterans Affairs (hereinafter, ``VA'').
Senator Tester was an original cosponsor. The bill was referred
to the Committee.
On January 12, 2017, Senator Heller introduced S. 114, the
proposed VA Choice and Quality Employment Act of 2017. S. 114
would require VA to submit an annual report on performance
awards and bonuses awarded to certain high-level VA employees.
Senator Casey was an original cosponsor. Senators Collins and
King were later added as cosponsors. The bill was referred to
the Committee.
On January 12, 2017, Senator Heller introduced S. 115, the
proposed Veterans Transplant Coverage Act. S. 115 would amend
title 38, U.S.C., to authorize the Secretary of Veterans
Affairs to provide for an operation on a live donor for
purposes of conducting a transplant procedure for a veteran.
Senator Cornyn was later added as a cosponsor. The bill was
referred to the Committee.
On March 9, 2017, Senator Murray introduced S. 591, the
proposed Military and Veteran Caregiver Services Improvement
Act of 2017. S. 591 would expand eligibility for the program of
comprehensive assistance for family caregivers to include
veterans who were injured or fell ill in the line of duty prior
to September 11, 2001; include child care, financial planning,
and legal services in the program of comprehensive assistance
for family caregivers; authorize the transfer of entitlement to
Post-9/11 education assistance to family members by veterans
who are in the program of comprehensive assistance for family
caregivers, without regard to length-of-service requirements;
expand eligibility for special compensation for members of the
uniformed services with catastrophic injuries or illnesses
requiring assistance in everyday living; authorize the VA to
provide certain caregiver assistance to family caregivers of a
member in receipt of monthly special compensation; authorize
flexible work schedules or telework for Federal employees who
are caregivers of veterans; designate a veteran participating
in the program of comprehensive assistance for family
caregivers as an adult with a special need for purposes of the
lifespan respite care program; establish an interagency working
group to review policies relating to the caregivers of veterans
and members of the Armed Forces; and require studies on members
of the Armed Forces who commenced service after September 11,
2001, and veterans who have incurred a serious injury or
illness, including a mental health injury, and their
caregivers. Senators Baldwin, Bennet, Blumenthal, Brown,
Cantwell, Collins, Coons, Durbin, Franken, King, Murphy,
Sanders, Schatz, Shaheen, Tester, and Warner were original
cosponsors. Senators Booker, Cardin, Casey, Cortez Masto,
Duckworth, Hirono, Kaine, Manchin, Markey, Menendez, Merkley,
Nelson, Peters, Stabenow, Van Hollen, Warren, and Wyden were
later added as cosponsors. The bill was referred to the
Committee.
On April 25, 2017, Senator Ernst introduced S. 925, the
proposed Veterans E-Health and Telemedicine Support Act of
2017, or VETS Act of 2017. S. 925 would authorize VA health
care professionals to provide treatment to patients via
telemedicine regardless of where the covered health care
professional or the patient is located. Senator Hirono was an
original cosponsor, and Senators Booker, Boozman, Grassley,
Hassan, Hatch, Kennedy, Rounds, Shaheen, Tester, Tillis, and
Udall were later added as cosponsors. The bill was referred to
the Committee.
On May 17, 2017, Senator Baldwin introduced S. 1153, the
proposed Veterans Acquiring Community Care Expect Safe Services
Act of 2017, or Veterans ACCESS Act. S. 1153 would require VA
to prohibit or suspend certain health care providers from
providing non-VA health care services to veterans. Senator
Moran was an original cosponsor. The bill was referred to the
Committee.
On May 25, 2017, Senator Crapo introduced S. 1279, the
proposed Veterans Health Administration Reform Act of 2017.
S. 1279 would authorize VA to furnish health care from non-VA
health care providers through the establishment of a Care in
the Community program. This program would include the creation
of an education program on health care options from VA and a
training program for the administration of non-VA health care.
S. 1279 would also make the reimbursement for emergency
treatment and urgent care furnished in a non-VA facility more
generous. Senator Risch was later added as a cosponsor. The
bill was referred to the Committee.
On June 8, 2017, Senator Brown introduced S. 1319, the
proposed Community Care Competency Act of 2017. S. 1319 would
require VA to establish a continuing medical education program
for non-VA medical professionals who treat veterans to increase
knowledge and recognition of medical conditions common to
veterans. Senator Durbin was later added as a cosponsor. The
bill was referred to the Committee.
On June 8, 2017, Senator Tester introduced S. 1325, the
proposed Better Workforce for Veterans Act of 2017. S. 1325
would amend VA authorities to improve the hiring, recruiting,
and training of employees by removing the limitation on
recruitment, relocation, or retention incentives. Senators
Crapo, Hassan, Kaine, McCaskill, and Moran, were original
cosponsors, and Senator Nelson was later added as a cosponsor.
The bill was referred to the Committee.
On June 27, 2017, Senator Sullivan introduced S. 1449, the
proposed Serving our Rural Veterans Act of 2017. S. 1449 would
authorize payment by the VA for training and supervision of
medical residents and interns at non-VA facilities. S. 1449
would also require VA to carry out a pilot program to establish
or affiliate with residency programs at facilities operated by
Indian tribes, tribal organizations, and the Indian Health
Service (hereinafter, ``IHS''). Senator Tester was an original
cosponsor. The bill was referred to the Committee.
On July 20, 2017, Senator Hoeven introduced S. 1611, the
proposed Veterans Access to Long Term Care and Health Services
Act. S. 1611 would authorize VA to enter into Veterans Care
Agreements (hereinafter, ``VCAs'') with health care providers
to furnish hospital care, medical services, or extended care
services if VA is unable to furnish the care. Senator Rounds
was an original cosponsor, and Senator Cassidy was later added
as a cosponsor. The bill was referred to the Committee.
On September 28, 2017, Senator Cassidy introduced S. 1871,
the proposed VA Provider Equity Act. S. 1871 would make a
doctor of podiatric medicine eligible for any supervisory
position to the same degree as a Veterans Health Administration
(hereinafter, ``VHA'') physician, and would increase the pay
grade of podiatrists to match the compensation of other VHA
surgeons, physicians, and dentists. Senators Baldwin, Donnelly,
Grassley, Heitkamp, Peters, Shaheen, and Stabenow were later
added as cosponsors. The bill was referred to the Committee.
On September 27, 2017, Senator Blumenthal introduced
S. 1873, the proposed Veteran Partners' Efforts to Enhance
Reintegration Act, or Veteran PEER Act. S. 1873 would require
the Secretary of Veterans Affairs to carry out a program to
establish peer specialists in Patient Aligned Care Teams
(hereinafter, ``PACT'') at VA medical centers (hereinafter,
``VAMC''). Senator Blunt was an original cosponsor, and
Senators Baldwin, Brown, Collins, Hassan, Heller, Rounds,
Warren, and Wicker were later added as cosponsors. The bill was
referred to the Committee.
On November 15, 2017, Senator Baldwin introduced S. 2134,
the proposed Andrew White Veterans Community Care Opioid Safety
Act. S. 2134 would require VA to establish processes to ensure
the safe practice of prescribing opioids by non-VA providers.
Senators Blumenthal, Brown, Capito, Manchin, Moran, and Tester
were original cosponsors, and Senator Hassan was later added as
a cosponsor. The bill was referred to the Committee.
Committee Hearing
On May 17, 2017, the Committee held a hearing on
legislation pending before the Committee. Testimony was
received by Jennifer S. Lee, M.D., Deputy Under Secretary for
Health for Policy and Services, Veterans Health Administration,
U.S. Department of Veterans Affairs; Louis J. Celli, Jr.,
Director, National Veterans Affairs and Rehabilitation
Division, The American Legion; Kayda Keleher, Associate
Director, National Legislative Service, Veterans of Foreign
Wars; Adrian Atizado, Deputy National Legislative Director,
Disabled American Veterans; Allison Jaslow, Executive Director,
Iraq and Afghanistan Veterans of America; and J. David Cox,
National President, American Federation of Government
Employees.
On June 7, 2017, the Committee held a hearing to examine
the Veterans Choice Program and the future of care in the
community. Testimony was received by the Honorable David J.
Shulkin, M.D., Secretary of Veterans Affairs, Department of
Veterans Affairs; Jeff Steele, Assistant Director, National
Legislative Division, The American Legion; Adrian Atizado,
Deputy National Legislative Director, Disabled American
Veterans; Carlos Fuentes, Director of the National Legislative
Service, Veterans of Foreign Wars; and Gabriel Stultz,
Legislative Counsel, Paralyzed Veterans of America.
On July 11, 2017, the Committee held a hearing on
legislation pending before the Committee, including two draft
bills authored by Senators Isakson and Tester, primarily on the
future of non-Department of Veterans Affairs health care. The
draft legislation from the Chairman and Ranking Member largely
informed the original bill reported from the Committee, which
became S. 2193, the Caring for Our Veterans Act (hereinafter,
``the Committee bill''). Testimony was received by Baligh
Yehia, M.D., Deputy Under Secretary for Health for Community
Care, Veterans Health Administration, Department of Veterans
Affairs; Louis J. Celli, Director, National Veterans Affairs
and Rehabilitation Division, The American Legion; Amy Webb,
National Legislative Policy Advisor, AMVETS; Adrian Atizado,
Deputy National Legislative Director, Disabled American
Veterans; and Gabriel Stultz, Legislative Counsel, Paralyzed
Veterans of America.
Committee Meeting
After reviewing the testimony from the foregoing hearings,
the Committee met in open session on November 29, 2017, to
consider the original bill, including provisions derived from
the legislation noted above, including the two draft bills
authored by Senators Isakson and Tester. The Committee voted,
by roll call vote, to report favorably to the Senate the
original bill at the Committee meeting.
Summary of the Original Bill as Reported
The original bill as reported, consists of 57 sections,
summarized below.
Section 1 provides a short title.
TITLE I--DEVELOPING AN INTEGRATED HIGH-PERFORMING NETWORK
SUBTITLE A--ESTABLISHING COMMUNITY CARE PROGRAMS
Section 101 would amend section 1703 of title 38, U.S.C.,
to establish a Veterans Community Care Program.
Section 102 would authorize VA to enter into VCAs with
providers in the community to provide health care to veterans.
Section 103 would authorize VA to enter into VCAs with
State Veterans Homes.
Section 104 would require VA to establish guidelines for
health care access and standards for quality.
Section 105 would authorize access to walk-in care for
eligible veterans.
Section 106 would require VA to perform market area
assessments at least every 4 years and to submit a strategic
plan for Congress at least every 4 years regarding an
assessment of health care demand and capacity.
Section 107 would apply the TRICARE contractor and
subcontractor compliance directive, Directive 2014-01 of the
Office of Federal Contract Compliance Programs of the
Department of Labor (hereinafter, ``DOL''), to VCAs established
in section 102.
Section 108 would authorize VA to deny, suspend, or revoke
the eligibility of a non-VA health care provider to participate
in the Veterans Community Care Program if the provider was
previously removed from employment by VA or had their medical
license revoked.
SUBTITLE B--PAYING PROVIDERS AND IMPROVING COLLECTIONS
Section 111 would establish a prompt payment process and
standards to which VA should adhere when paying non-VA
providers and require claims to be processed by a contracted
third party administrator or other non-VA entity.
Section 112 would authorize VA to pay for services not
subject to an agreement.
Section 113 would authorize VA to collect from a third
party for care provided to non-veterans and authorize VA to
seek collections when it pays for care rather than just
furnishes it.
Section 114 would authorize VA to enter into an agreement
with a third party entity to electronically process health care
claims from community providers.
SUBTITLE C--EDUCATION AND TRAINING PROGRAMS
Section 121 would require VA to develop and administer an
education program to inform veterans about their health care
options.
Section 122 would require VA to develop and administer a
training program for VA employees and contractors on how to
administer non-VA health care programs.
Section 123 would establish a program to provide continuing
medical education to non-VA medical professionals.
SUBTITLE D--OTHER MATTERS RELATING TO NON-DEPARTMENT OF VETERANS
AFFAIRS PROVIDERS
Section 131 would require VA to establish processes to
ensure safe opioid prescribing practices by non-VA providers.
Section 132 would authorize VA to share certain medical
record information with non-VA entities for purposes of
providing health care and with third parties for the recovery
of the cost of certain care.
Section 133 would require competency standards for non-VA
health care providers that treat injuries or illnesses in
clinical areas that VA has a special expertise.
SUBTITLE E--OTHER NON-DEPARTMENT HEALTH CARE MATTERS
Section 141 would require VA to submit to Congress a
justification for any new supplemental appropriations request
submitted outside of the standard budget process.
Section 142 would authorize VA, beginning in fiscal year
(hereinafter, ``FY'') 2019, to use any remaining amounts in the
Veterans Choice Fund to pay for any health care services under
chapter 17 of title 38, U.S.C., through non-VA providers.
Section 143 would provide a sunset date for the Veterans
Choice Program of December 31, 2018.
Section 144 would repeal and replace existing authorities
to account for changes made by section 101 of the Committee
bill to consolidate and create the Veterans Community Care
Program.
TITLE II--IMPROVING DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE DELIVERY
SUBTITLE A--PERSONNEL PRACTICES
PART I--ADMINISTRATION
Section 201 would create a new authority to authorize VA
health care professionals to practice telemedicine regardless
of the location of the provider or patient during the
treatment.
Section 202 would make a podiatrist eligible for any
supervisory position to the same degree as a VHA physician, and
would increase the pay grade of podiatrists to match the
compensation of other VHA surgeons, physicians, and dentists.
Section 203 would include certified clinical perfusionists
in the list of excepted positions and convert such positions to
full title 38 status.
Section 204 would amend the statutory requirements for the
position of the Chief Officer of the Readjustment Counseling
Service (hereinafter, ``RCS'').
Section 205 would make an exception for increasing the
compensation scale and raises for VAMC directors and directors
of Veterans Integrated Service Networks (hereinafter,
``VISNs'').
Section 206 would require VA to identify and fully staff
all mental health vacancies and all primary care and mental
health vacancies in PACTs.
Section 207 would require VA to make certain staffing
capacity information publicly available on a VA Internet
website.
Section 208 would require VA to integrate peer specialists
into PACT.
Section 209 would require VA to establish a pilot program
to increase the use of medical scribes at VA facilities.
Section 210 would express the sense of Congress that VA
should make the resolution of staffing shortages a priority.
PART II--EDUCATION AND TRAINING
Section 211 would require VA to increase the number of
graduate medical education (hereinafter, ``GME'') positions by
up to 1,500 and authorize VA to pay for the time the residents
are training at non-VA facilities.
Section 212 would require VA to establish a pilot program
to establish or affiliate with GME residency programs at
facilities operated by Indian tribes, tribal organizations, and
the IHS in rural areas.
Section 213 would authorize VA to reimburse any board-
certified advanced practice registered nurse (hereinafter,
``APRN'') up to $1,000 per year for continuing professional
education.
Section 214 would increase the maximum amount of payments
that VA could make for participants of VA's Education Debt
Reduction Program (hereinafter, ``EDRP'').
Section 215 would authorize VA to establish a demonstration
program on training and employment of alternative dental health
care providers for dental health care services for veterans in
rural and underserved communities.
PART III--OTHER PERSONNEL MATTERS
Section 221 would establish an exception to a previous
limitation on awards and bonuses for recruitment, relocation,
and retention.
Section 222 would require VA to submit an annual report on
performance awards and bonuses awarded to certain high-level VA
employees.
Section 223 would expand the definition of compensation to
include pay earned by employees when performing duties
authorized by the Secretary or when the employee is approved to
use annual, sick, family medical, military, or court leave, or
other paid absences for which pay is not already regulated.
Section 224 would establish a higher maximum amount of
basic pay for registered nurses.
SUBTITLE B--IMPROVEMENT OF UNDERSERVED FACILITIES OF
THE DEPARTMENT
Section 231 would require VA to develop criteria for the
designation of certain VA medical facilities as underserved and
a plan to address the problem of underserved facilities.
Section 232 would require VA to establish a pilot program
to provide tuition reimbursement and loan repayment for VA
health care providers at underserved facilities.
Section 233 would require VA to establish a program to
furnish mobile deployment teams to underserved facilities.
Section 234 would require VA to consider Vet Center
employees eligible for EDRP.
SUBTITLE C--CONSTRUCTION AND LEASES
Section 241 would modify the definitions of major medical
facility project and major medical facility lease.
Section 242 would authorize VA to enter into agreements
with other Federal agencies for planning, designing,
constructing, and/or leasing shared medical facilities.
Section 243 would modify the review process in VA's
issuance of enhanced-use leases.
Section 244 would authorize VA to spend no more than $117.3
million on the East Bay Community Based Outpatient Clinic, the
Central Valley Engineering and Logistics support facility, and
enhanced flood plain mitigation as part of the realignment of
medical facilities in Livermore, California.
SUBTITLE D--OTHER HEALTH CARE MATTERS
Section 251 would direct VA to issue grants to non-VA
entities to study the feasibility of using wellness programs in
providing mental health counseling to veterans and their family
members using Vet Centers.
Section 252 would authorize VA to provide for transplant
procedures on live donors regardless of whether the donor is a
veteran.
Section 253 would express the sense of the Senate that VHA
should not be privatized.
TITLE III--FAMILY CAREGIVERS
Section 301 would expand eligibility for VA's Program of
Comprehensive Assistance for Family Caregivers, in two phases,
to all eras of veterans.
Section 302 would require VA to implement an information
technology (hereinafter, ``IT'') system that fully supports the
Family Caregiver Program and allows for data assessment and
comprehensive monitoring.
Section 303 would modify the requirements for VA's annual
report to Congress on the Family Caregiver Program.
TITLE IV--APPROPRIATION OF AMOUNTS
Section 401 would authorize and appropriate $1 billion to
VA to be used for educational assistance for providers, the
increase of GME positions, and recruitment, relocation, and
retention incentives.
Section 402 would authorize and appropriate $4 billion to
be used for the Veterans Choice Fund.
Background and Discussion
TITLE I--DEVELOPING AN INTEGRATED HIGH-PERFORMING NETWORK
SUBTITLE A--ESTABLISHING COMMUNITY CARE PROGRAMS
Sec. 101. Establishment of Veterans Community Care Program.
Section 101 of the Committee bill, an original provision,
would amend section 1703 of title 38, U.S.C., to provide VA the
authority to build a network of providers in the community.
Access to the network would be dependent on whether the veteran
and their VA provider agree it would be in the best interest of
the veteran to utilize non-VA care, or if the quality and
access of a VA medical service line does not equal the quality
standards in the community and VA access guidelines.
Background. Section 1710 of title 38, U.S.C., requires VA
to provide hospital care and medical services to eligible
veterans. Section 1703 of title 38, U.S.C., authorizes VA to
contract with non-VA facilities and providers to furnish
hospital or medical services to eligible veterans when VA is
not capable of providing economical care because of
geographical inaccessibility or due to an inability to furnish
such care or services required. Sections 1725 and 1728 of title
38, U.S.C., authorize VA to reimburse for certain types of
care, such as emergency treatment, at non-VA facilities.
Section 1786 of title 38, U.S.C., authorizes VA to provide
necessary post-delivery care and services. Section 8111 of
title 38, U.S.C., authorizes VA to enter into sharing
agreements at other government facilities. Section 8153 of
title 38, U.S.C., authorizes a VA facility to enter into a
contract or agreement with non-VA health care entities to
secure health care services that are either unavailable or not
cost-effective to provide at a VA facility. Section 101 of
Public Law (hereinafter, ``P.L.'') 113-146, the Veterans
Access, Choice, and Accountability Act of 2014 (hereinafter,
``P.L. 113-146''), authorized veterans to receive care in the
community if they would wait more than 30 days for care in a VA
facility or lived more than 40 miles from a VA facility
(hereinafter, ``Veterans Choice Program'').
Committee Bill. Section 101(a)(1) would amend Section 1703
of title 38, U.S.C., to authorize care at non-VA facilities.
Section 1703(a), as amended, would establish the Veterans
Community Care Program to provide veterans with care in the
community under certain circumstances and direct the Secretary
to provide care coordination for veterans using the program. At
a minimum, VA would ensure appointments are scheduled, ensure
continuity of care, coordinate with adjacent regions should a
veteran receive care in an adjoining network, and ensure a
veteran does not experience a lapse of care or has an unusual
or excessive burden in accessing care. The Committee expects
that VA will execute all reasonable actions to ensure that a
veteran receives a seamless transition from VA to community
care and back to VA. The Committee believes that for this
program to be a success for veterans, VA must provide high-
quality customer service at every point in the process and
truly put a veteran's best interest at the forefront of this
endeavor.
Section 1703(b), as amended, would define that a covered
veteran for the purposes of this section is a veteran enrolled
under section 1705 of title 38, U.S.C., or is not enrolled but
is otherwise entitled to care at VA.
Section 1703(c), as amended, would specify that eligible
non-VA health care providers would be providers who participate
in the Medicare program, Federally Qualified Health Centers
(hereinafter, ``FQHCs''), facilities funded by IHS, or the
Department of Defense (hereinafter, ``DOD'').
Section 1703(d), as amended, would provide care in the
community when VA does not offer the service the veteran needs,
if the veteran resides in a state that does not have a full-
service VA medical facility, or the veteran was eligible for
the Veterans Choice Program, as of the day before the date of
enactment of the Committee bill, because they lived more than
40 miles from a VA facility. Additionally, if the veteran and
the veteran's primary care provider agree that it would be in
the best medical interest of the veteran, they would receive
care in the community. In determining whether care in the
community is necessary, the provider should consider the
driving distance between the veteran and the facility that
provides the service the veteran needs; the nature of the care
required; the frequency of the treatments needed; whether VA
provides the service needed; whether the appointment can be
provided within the access standards established by VA or a
time frame a provider determines is clinically necessary; the
veteran faces an unusual or excessive burden to access hospital
care or services; or other conditions as determined by VA. The
Committee does not intend for this to be an exhaustive list in
determining the circumstances in which a veteran would be
eligible for care in the community. The conditions specified in
this subsection represent some factors the VA primary care
provider and the veteran should take into consideration when
determining whether to seek care in the community. The
Committee also does not intend that the conversation between
the veteran and their provider must be an in-person meeting.
The conversation of where to receive care could be over the
phone, through electronic mail, or with a representative of the
provider.
Section 1703(e), as amended, would, in paragraph (1),
authorize the Secretary to furnish hospital care, medical
services, or extended care services through a health care
provider specified in subsection (c) if a VA medical service
line is not providing care that meets the access guidelines and
standards for quality as established by the Secretary.
When measuring access, subparagraph (B) would require the
Secretary to measure access of the VA medical service line when
compared with the same medical service line at a different VA
facility. Subparagraph (B) would also require the Secretary to
measure quality at a VA medical service line by comparing it
with two or more distinct quality measures at non-VA medical
services lines. The Committee intends that as VA is able to
compare more VA medical service line quality measures with the
same quality measures in the community, that the scope of
measurements will become more robust.
Section 1703(e) would require that not more than three
medical service lines at any one VA facility be eligible under
the authority provided under paragraph (1). Further, the
authority provided in paragraph (1) would be limited to not
more than 36 medical service lines nationwide. This means that
not more than 36 instances of this authority may be used
concurrently. The Committee believes that given the
requirements in 1703(g), as amended, 36 medical service lines
is a manageable number for VA to facilitate this authority and
the concurrent remediation of a triggered service line.
Authority provided in paragraph (1) of 1703(e) would cease
when the remediation described in subsection (g) is complete.
The Committee intends that VA will take every measure to ensure
a smooth transition of care back to VA for the veteran.
Section 1703(e) would require VA to publish in the Federal
Register yearly and take all reasonable steps to provide direct
notice to veterans affected by the authority provided in
paragraph (1). VA would be required to provide to veterans the
time period during which care could be accessed in the
community under this authority; the location or locations such
care in the community can be accessed; and the clinical
services available at each location under this authority. The
Committee intends that this information be clear and concise so
that no veteran is unsure of where to seek health care
services.
Finally, it would be at the election of a veteran to use
care in the community under the authority provided in section
1703(e)(1).
Section 1703(f), as amended, would provide for a clinical
appeals process similar to the appeals process a veteran may
follow in appealing a clinical decision for care provided
within a VA facility. The Committee intends that this clinical
appeals process be expedient so that no veteran faces an undue
delay in health care services. The Committee strongly
encourages VA to establish one clinical appeals process to be
applied across VHA.
Section 1703(g), as amended, would require that not later
than 30 days after VA determines that a medical service line is
providing untimely care when compared with the same service
line at other VA facilities or has deficient quality when
compared with community providers, an assessment be submitted
to Congress of the factors that led the Secretary to make such
a determination. Included in that assessment must be a plan
with specific actions, and the time to complete them, the
Secretary intends to take to remediate the service line. The
Committee intends that while veterans are provided the
opportunity to seek community care under new section 101(e)
that VA engage in robust efforts to remediate the service line.
Section 1703(g)(1)(A)-(G) sets forth the actions the
Secretary should consider when developing the assessment
required under 1703(g). Included among the actions the
Secretary should consider to remediate the service line are
special hiring authorities, including EDRP and recruitment,
relocation and retention incentives; utilizing direct hiring
authority; providing improved training opportunities; acquiring
improved equipment; making structural modifications to the
facility used by the service line; and other actions the
Secretary considers appropriate. The Committee intends that the
Secretary utilize all appropriate authorities to address
deficiencies in a service line.
Section 1703(g)(2) would require the Secretary to identify
those individuals at the local, VISN, and Central Office-levels
responsible for the remediation efforts for a service line
identified under new section 1703(e). The Committee believes
that this level of accountability is necessary to ensure that
appropriate actions are being taken to successfully remediate a
service line.
Section 1703(g)(3) would require that within 180 days after
the assessment required in 1703(g)(1), the Secretary submit to
Congress a report on the progress of that medical service line
in complying with the access guidelines and meeting the
standards of quality established by the Secretary and any other
actions the Secretary will take to ensure the service line is
remediated. Further, 1703(g)(4) would require an annual
analysis of the remediation actions and costs of such actions
taken with respect to every service line triggered under
1703(e). These reporting requirements signal the Committee's
intended level of oversight over the remediation process.
The Committee intends that the remediation of service lines
be vigorously undertaken with the ultimate goal of veterans
having access to a high-quality level of care at VA.
Section 1703(h), as amended, would direct the Secretary to
establish access guidelines under section 1703B and quality
standards under section 1703C for measuring whether the
conditions under which medical care is authorized to be
furnished through non-VA entities is met.
The Secretary would be directed to ensure these guidelines
and standards, established under paragraph (1), provide
veterans, VA employees, and community health care providers
with relevant comparative information.
This subsection would also direct the Secretary to consult
with Federal entities, including the DOD and the Department of
Health and Human Services (hereinafter, ``HHS''), the private
sector, and nongovernmental entities in establishing the
guidelines and standards.
No later than 270 days after the bill's enactment, the
Secretary would be required to submit a report to Congress
detailing the access guidelines and quality standards
established under paragraph (1) and their development. At least
every 3 years, the Secretary would be required to conduct a
review of the guidelines and standards established under
paragraph (1), and submit a report to Congress if there are any
modifications.
This subsection would also direct the Secretary to ensure
that community providers furnishing medical services under the
authority of the Community Care program are able to meet the
access guidelines and quality standards that the Secretary
establishes under paragraph (1).
Section 1703(i), as amended, would allow VA to develop a
tiered network to ensure high-quality health care, medical
services, or extended care services would be available to
veterans under this section. However, in developing a tiered
network, VA is directed to not prioritize one provider over
others in another tier.
Section 1703(j), as amended, would direct VA to enter into
contracts to establish a network of health care providers. The
section would also direct VA, to the extent practicable, to
allow veterans to self-schedule appointments for care in the
community using smartphone technology and direct VA, to the
extent practicable, to schedule appointments for veterans in
the community. However, the Committee intends that VA give
consideration to the contractor performing the scheduling if a
particular VAMC is not able to schedule in-house. In addition,
section 1703(j) would direct VA to terminate a contract if an
entity is not meeting certain criteria. Under the Veterans
Choice Program, VA did not require a Third Party Administrator
(hereinafter, ``TPA'') to monitor the time an individual is on
hold or establish a standard for TPAs to adhere to. The
Committee expects the Secretary to require future contractors
under the Veterans Community Care Program to monitor the period
of time an individual is placed on hold, assess the average
time an individual is on hold disaggregated by geographic area
and establish hold-time standards for contractors to adhere to.
Further, a TPA that provided call center services for the
Veterans Choice Program was not precluded from establishing a
policy that limited the ability for an individual to
troubleshoot more than three claims. Medical providers that
accepted veterans under the Veterans Choice Program expressed
deep frustration at this policy because it limited the ability
of medical providers to troubleshoot multiple outstanding
claims. The Committee expects the Secretary to require future
contractors under the Veterans Community Care Program to not
limit the amount of claims an individual can troubleshoot per
call. Section 1703(j) would also require VA to allow providers
treating veterans under a contract or agreement under title 38,
U.S.C., the ability to continue to provide care through the
Veterans Community Care Program. Finally, section 1703(j) would
require that when VA provides notice to an entity that is
failing to meet contractual obligations, it would also provide
a report to the Senate and House Veterans' Affairs Committees
on such failure. Contractors have demonstrated significant
challenges in executing their obligations under the Veterans
Choice Program, to the detriment of the health care services
provided to veterans. As such, the Committee believes that
veterans would benefit with Congress' greater visibility into
whether non-VA providers are meeting contractual obligations.
Section 1703(k), as amended, would direct that the rates VA
would pay for care in the community may not exceed the rates
established by the Centers for Medicare and Medicaid Services
(hereinafter, ``CMS''). The section gives VA flexibility with
the rates for highly rural areas, the State of Alaska, and
States with an All-Payer Model Agreement with CMS. The section
would direct VA to negotiate rates that are not covered by CMS
and, to the greatest extent practicable, use a value-based
reimbursement model to promote the provision of high-quality
care. While VA would be allowed to enter into value-based
agreements, the Committee intends for the agreements with IHS
to be based on the IHS fee schedule and not a value-based
agreement.
Section 1703(l), as amended, would direct VA to bill
veterans' other health insurance for non-service connected
conditions treated through the Veterans Community Care Program.
Section 1703(m), as amended, would require that a veteran not
pay more for care received through the Veterans Community Care
Program than they would for care received in a VA facility.
Section 1703(n), as amended, would require VA to monitor the
types of care and services provided under the authorities in
this section and submit annual reports to Congress. Section
1703(o), as amended, would direct that VA cannot limit the type
of care and services provided under the Veterans Community Care
Program. Section 1703(p), as amended, would define a medical
service line and appropriate committees of Congress.
Section 101(a)(2) would provide for a clerical amendment to
the table of contents at the beginning chapter 17 of title 38,
U.S.C.
Section 101(b) would provide an effective date for the
Veterans Community Care Program. The section would be effective
30 days after VA submits a report required under section
101(q)(2) of P.L. 113-146 or on the date on which VA
promulgates regulations, whichever is later. Section 101(c)
would direct VA to prescribe regulations within 1 year of
enactment.
Section 101(d) would require VA to continue existing
contracts, memorandum of agreements, and memorandum of
understanding VA had entered into prior to the enactment of
this act with Alaska Native and American Indian health systems
and any agreements VA entered into with the Native Hawaiian
health care system under section 103 of P.L. 113-146. It is the
intent of this Committee that this legislation not supercede
the authorities and agreements put into place to support these
unique populations of veterans.
Sec. 102. Authorization of agreements between Department of Veterans
Affairs and non-VA providers.
Section 102 of the Committee bill would authorize VA to
enter into agreements to provide hospital care, medical care or
extended care services on behalf of veterans.
Background. Under section 1703 of title 38, U.S.C., VA can
enter into contracts for hospital care and medical services in
non-VA facilities when VA facilities are not capable of
furnishing economical hospital care or medical services because
of geographical inaccessibility or are not capable of
furnishing the care or services required.
Committee Bill. Section 102(a) would create a new section
1703A to authorize VA to purchase hospital care, medical
services and extended care services as authorized by chapter 17
when VA cannot furnish such care itself or through existing
contracts or sharing agreements. Section 1703A(a)(2)(A) would
authorize VA to use VCAs when the Secretary, or any VA official
authorized by the Secretary, determines the veteran's medical
condition, the travel involved, the nature of the care or
services required, or a combination of these factors make the
use of VA facilities or existing contracts or sharing
agreements impracticable or inadvisable.
It is the Committee's intent that section 102 would improve
VA's flexibility to meet veterans' demand for hospital care,
medical services and extended care services by authorizing VA
to enter into VCAs that, in general, would not be subject to
competition or other requirements associated with Federal
contracts.
Section 1703A(a)(2)(B) would set forth requirements for
review of VCAs, including the requirement to review each VCA of
material size for at least 6 months within 2 years of it going
into effect, and no less often than every 4 years thereafter,
to determine if it is practical or advisable to provide such
care or services within VA or through a contract or sharing
agreement. While the Committee believes this authority is
necessary to provide veterans high-quality and timely care in
instances when VA cannot provide the health care services
needed, it is the Committee's intent that this authority be
limited and routinely reviewed to determine whether the VCA
contractors would more appropriately be part of VA's network of
providers.
Section 1703A(a)(3)(A) would authorize the Secretary to
determine whether a VCA is of ``material size'' except for
those for extended care services. Such VCAs would be considered
to be of ``material size'' if they exceed $5 million annually.
It is the Committee's intent that these agreements be reviewed
to ensure that taxpayer dollars are being spent appropriately,
that certain VCAs might be more appropriately be made part of
the VA's community care network and that veterans are receiving
high-quality and timely care under the agreement.
Section 1703A(a)(3)(B) would authorize the Secretary to
adjust the dollar amounts previously determined to be of
``material size'' by publishing a new amount in the Federal
Register to account for changes in the cost of health care
based upon recognized health care market surveys and other
available data.
Section 1703A(b) defines entities and providers that would
be eligible to provide services under a VCA. Eligible providers
would include participants of the United States Medicare and
Medicaid programs or other providers the VA Secretary deems
appropriate.
Section 1703A(c) would require the Secretary to establish
in regulation a process for the certification or
recertification of eligible entities or providers. VA would
include as part of its certification plan: deadlines for
actions on applications for certification; standards for
approval or denial of a certification, duration of a
certification, revocation of a certification, and
recertification of an eligible entity or provider; require the
denial of a certification if the provider is excluded under
other Federal laws from furnishing care or services for the
Federal government; and procedures for screening entities and
providers for the risk of fraud, waste, and abuse. The
Committee intends that this process be straightforward and
without undue burden on providers.
Section 1703A(d) would establish VCA rates, to the maximum
extent practicable, to be Medicare rates. Section 1703A(e)
would establish the terms of the Veterans Extended Care
Agreements to specify the rates VA would reimburse, ensure the
return of medical records to VA, ensure that the provider does
not attempt to collect compensation from a third party or
health care plan for extended care services provided under the
agreements, ensure that only care authorized by VA would be
provided under the agreement, and would establish a methodology
for providers to submit bills to VA. Section 1703A(f) would
establish the circumstances under which an agreement could be
discontinued or not renewed. Section 1703A(g) would direct VA
to establish a procedure to monitor the quality of care
provided through the agreements. Section 1703A(h) would direct
VA to establish procedures for providers to present disputes
related to the agreements.
Section 1703A(i) would set forth the applicability of
Federal laws. VCAs would not be treated as an award for the
purpose of Federal laws that would require the use of
competitive procedures to furnish care and services or a
Federal contract for the acquisition of goods or services for
purposes of Federal laws governing Federal contracts for the
acquisition of goods or services.
Section 1703A(i)(2)(A) notes that VCAs would not be subject
to any law for which Medicare servicers or suppliers are not
subject. Section 1703A(j) would require that veterans treated
under VCAs be subject to the same terms as if they had been
treated in a VA facility. Section 1703A(k) would require that
the Secretary promulgate regulations to carry out section 102.
Section 102(b) would make a clerical change to add section
1703A to the table of contents for chapter 17 of title 38,
U.S.C.
Sec. 103. Conforming amendments for State veterans homes.
Section 103 of the Committee bill would amend section
1745(a) of title 38, U.S.C., to align VA's procurement
authority with State Veterans Homes to match that provided for
in Section 103 of the Committee Bill.
Background. Under section 1745 of title 38, U.S.C., VA can
enter into contracts or agreements with state veterans homes to
provide nursing home care for eligible veterans.
Committee Bill. Section 103(a) would make conforming
technical amendments to section 1745(a) of title 38, U.S.C., to
reflect the new authority provided to VA for the procurement of
hospital care, medical services, and extended care services
that, in general, would not be subject to the competition or
other requirements associated with Federal contracts, while
still subjecting eligible entities and providers to all laws
that protect against employment discrimination or that
otherwise ensure equal employment opportunities.
Section 1745(a), as amended, would delete the reference to
agreements under section 1720(c)(1), which provide for
agreements with non-VA nursing homes.
Section 1745(a) would add a new subsection (4)(A) providing
that the Secretary or a designated VA official may enter into
agreements with State Veterans Homes to provide nursing home
services to eligible veterans that are not subject to the use
of competitive contracting practices for furnishing hospital
care and medical services.
Section 1745(a) would add a new subsection (B)(i)
specifying that a State Veterans Home that enters into an
agreement under section 1745(a) of title 38, U.S.C., is not
subject to any provision of law to which service providers and
suppliers of the Medicare program under title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.) are not subject in
executing an agreement under this section.
Section 1745(a) would add a new subsection (B)(ii)(I)
specifying that a State Veterans Home that enters into an
agreement under section 1745(a) of title 38, U.S.C., is subject
to all provisions of law regarding integrity, ethics, or fraud
that subject a person to criminal or civil penalties.
Section 1745(a) would add a new subsection (B)(ii)(II)
specifying that a State Veterans Home that enters into an
agreement under section 1745(a) of title 38, U.S.C., is subject
to all provisions of law that protect against employment
discrimination or that otherwise ensure equal employment
opportunities.
Section 1745(a) would add a new subsection (B)(iii)
specifying that a State Veterans Home that enters into an
agreement under section 1745(a) of title 38, U.S.C., is not to
be treated as a Federal contractor or subcontractor for
purposes of chapter 67 of title 41, U.S.C. (known as the
``McNamara-O'Hara Service Contract Act of 1965'').
Finally, section 103(b) would specify that the new
provisions in section 1745(a), as amended by section 103(a),
shall apply to care provided on or after the date the Secretary
makes effective the regulations that carry out Section 103.
Sec. 104. Access guidelines and standards for quality.
Section 104 of the Committee bill, an original provision,
would, through a new section 1703B in title 38, U.S.C., direct
VA to consult with other pertinent Federal entities to examine
health care access measurements and establish local
benchmarking access guidelines. Section 104 would also create a
new section 1703C directing VA to establish standards for
quality for hospital care, medical services or extended care
services provided at VA facilities and non-VA facilities.
Background. In April 2017, VA introduced a new website,
www.accesstova.va.gov, to increase transparency on patient wait
times and quality of care data. VA provides the wait times of
veterans for certain types of care and services and publishes
those wait times, by facility, on its website. When data is
available, the VA website also compares the wait time to the
average wait time in the community to determine whether the
wait time for care at VA is better than or worse than the
average wait for care in the local community.
VA also tracks the quality of care delivered within its
facilities and provides the information on its access and
quality website, as well as reports certain measures to the CMS
Hospital Compare website. In a Government Accountability Office
(hereinafter, ``GAO'') report titled ``VA Should Improve the
Information It Publicly Reports on the Quality of Care at Its
Medical Facilities,'' GAO found that VA reports health care
quality measures on two separate VA websites, the access and
quality website and an older website. As of June 2017, the
access and quality website provided information on 15 of the
110 measures that VA reports on its older website.
Additionally, GAO found that VA may not be ensuring that the
health care quality measures are both complete and accurate.
GAO recommended that VA report a broader range of health care
quality measures in an accessible and understandable manner on
its website and conduct a systematic assessment across VAMCs to
ensure the accuracy and completeness of the data used to inform
the health care quality metrics. The Committee recognizes that
VA plans to expand the access and quality website to include
additional measures and encourages VA to continue to focus its
efforts on ensuring the content is accessible and
understandable for veterans seeking to make informed decisions
about where they receive their health care. The Committee also
expects the access guidelines and standards for quality
established under this section to be incorporated into the
access and quality website where applicable.
Committee Bill. Section 104(a) would add new sections 1703B
and 1703C to title 38, U.S.C., to direct VA to create access
guidelines and standards for quality of health care veterans
receive from VA and non-VA providers.
Section 1703B would direct VA to develop local benchmarking
access guidelines that would be used to inform both providers
and veterans when making clinical decisions regarding the
timeliness of veterans care. When developing these guidelines,
VA would be directed to consult with other pertinent Federal
entities, including, but not limited to, DOD, HHS, and CMS, to
study health care access measurements.
Section 1703C would direct VA to implement standards for
quality that apply to care provided at VA and non-VA
facilities. Specifically, 1703C(a) would direct VA to develop
standards for the quality of care provided under section 1703,
as amended by section 101 of the Committee bill, in
coordination with other pertinent Federal entities, including,
but not limited to, DOD, HHS, and CMS. In developing these
standards, VA is to consider existing health care quality
measures that are applied to public and private health care
systems. VA would be directed to collect and consider data,
such as, a survey of veterans to assess their satisfaction with
their care; datasets that include, at a minimum, timely care,
effective care, safety (including complications, readmissions,
and death), and efficiency with which the care was provided.
Section 1703C(b) would direct VA to not later than 1 year
after the standards for quality are established to publish the
ratings for those quality measures on the CMS Hospital Compare
website. To ensure VA has the most up to date standards of
quality, section 1703C(b) would also direct VA to publish
potential changes to the standards for quality in the Federal
Register, not later than 2 years after establishing the initial
standards for quality.
In establishing access guidelines and standards for
quality, the Committee directs VA to consider the nature of
care provided to veterans and the profile of the patient
receiving that care. For instance, veterans with spinal cord
injuries may be readmitted for wound care more than veterans
with other injuries.
Section 104(b) would provide a clerical amendment to amend
the table of sections in Chapter 17 of title 38, U.S.C.
Sec. 105. Access to walk-in care.
Section 105 of the Committee bill, an original provision,
would direct the Secretary to establish procedures and
regulations to ensure eligible veterans are able to access
walk-in care from qualifying non-VA entities or providers.
Background. P.L. 113-146 amended chapter 17 of title 38,
U.S.C. to allow veterans to seek and receive medical care from
non-VA entities if VA cannot schedule an appointment within 30
days of the clinically indicated date, their residence is more
than 40 miles from a VA facility with a primary care physician,
or they are faced with an unusual or excessive burden to travel
to the closest VA medical facility. The goal of P.L. 113-146
was to expand veterans' access to timely and quality care,
particularly when a VA facility was unable to provide it. In
April 2017, VA began a pilot program in Phoenix to allow
veterans to seek non-emergency and non-urgent care at CVS
``Minute Clinics.'' The purpose of the program is to help
veterans receive care in a convenient manner at these
facilities when ``clinically appropriate.''
Committee Bill. Section 105 would amend chapter 17 of title
38, U.S.C. by creating a new section 1725A to provide walk-in
care from non-VA entities or providers. The Committee's intent
in authorizing access to walk-in care is to offer veterans
convenient care for non-urgent health care needs.
Section 1725A(a) would direct the Secretary to establish
procedures and regulations to ensure eligible veterans are able
to access walk-in care from qualifying non-VA entities or
providers. The Committee believes that the Secretary should
make clear what health care conditions are non-urgent and
establish a mechanism, such as, an advice line, to help
veterans determine whether care under this section is
appropriate to meet their health care needs.
Section 1725A(b) would define eligible veterans as those
who are enrolled under chapter 1705(a) of title 38, U.S.C. and
who have been enrolled and have received medical care from VA
within the 24-month period preceding the furnishing of walk-in
care under this new program.
Section 1725A(c) would direct that a qualifying non-VA
entity or provider is one that has entered into a contract with
the Secretary in order to provide these services, and section
1725A(d) would allow veterans to seek walk-in care at FQHCs
when appropriate. It is the Committee's intent that the
authority in this section be exercised nation-wide, among
several types of entities or providers to ensure adequate
coverage, so that all veterans have the option of utilizing
this convenient, walk-in care. Section 1725A(e) would direct
the Secretary to ensure there is a continuity of care for
veterans receiving walk-in care, including a mechanism to
receive medical records from the walk-in clinics.
Section 1725A(f) would establish the procedures for copays
for walk-in care. Those veterans not required to pay a
copayment for VA medical services would have access to two
walk-in visits per year without requiring a copayment. All
visits thereafter would require a copayment determined by a
sliding copayment scale as established by the Secretary.
Veterans who are required to pay a copayment for medical
services provided by VA, would be required to pay their regular
copayments for the first two walk-in visits within a calendar
year and would be required to pay a higher copayment, as
determined by the Secretary, for additional visits. It is the
Committee's expectation that the higher copayment amount not
exceed $50 per visit.
Section 1725A(g) would require the Secretary to publish
regulations and rules, to carry out Section 105, no later than
1 year after the enactment of the bill. Section 1725A(h) would
define walk-in care as non-emergent care provided by a
qualifying non-VA entity or provider that furnishes episodic
care and not longitudinal management of conditions.
Section 105(b) would provide an effective date as the date
on which final regulations are promulgated. Section 105(c)
would provide a clerical amendment to amend the table of
sections in Chapter 17 of title 38, U.S.C.
Sec. 106. Strategy regarding the Department of Veterans Affairs High
Performing Integrated Health Care Network.
Section 106 of the Committee bill, a freestanding original
provision, would require the Secretary to perform market area
assessments at least every 4 years and prescribe the elements
that need to be included in the assessments. Section 106 of the
Committee bill would also direct VA to submit a strategic plan
to Congress every 4 years. The strategic plan would provide
information on the health care capacity provided at each VA
facility, the capacity provided through community care
providers, and the demand for health care disaggregated by
geographic market areas.
Background. VA intends to perform market area assessments
to analyze the health care demand and service-delivery capacity
in each of its 96 health care markets.\1\ The methodology for
the market area assessments was developed and validated through
recent pilots in three market areas. Private-sector experts
will enable VA market-assessment teams to assess the current
and future veteran demand for medical care, the health care
services available at VA, and the health care services
available in the local community.\2\ While the Committee is
pleased VA is conducting this assessment, the Committee
believes VA needs a more coordinated approach and a plan to
utilize the assessments to better manage the health care
provided under laws administered by VA.
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\1\``VA Market Area Health System Optimization;'' briefing to
Senate Committee on Veterans' Affairs, September 25, 2017.
\2\Statement of Regan L. Crump, Assistant Deputy Under Secretary
for Health for Policy and Planning, House Committee on Veterans'
Affairs, October 12, 2017.
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Committee Bill. Section 106 would require VA to conduct
quadrennial market area assessments and develop an analytically
sound strategic plan based on information provided in the
market area assessments. Specifically, section 106(a) would
direct VA to conduct market area assessments every 4 years that
would include an assessment of the demand for health care from
VA disaggregated by geographic area; an inventory of the health
care capacity at VA facilities; the capacity, number of
providers, geographic location of the providers and types of
care and services to be provided at non-VA facilities; capacity
assessment from other Federal direct delivery systems and non-
contracted health care providers regarding their ability to
provide care to veterans; VA academic affiliates providing care
to veterans; the effects on the capacity of health care by the
access guidelines and standards for quality established under
section 1703(h), as amended by section 101; and the number of
appointments for care at VA and non-VA facilities. This section
would direct VA to submit the market area assessments to the
appropriate committees of Congress. Section 106(a) further
directs VA to use the market area assessment to determine the
capacity of the provider networks established under section
1703(j), as amended by section 101, and to inform the
President's Budget Request for VA. Section 106(a) would take
effect September 30, 2018.
Section 106(b) would direct VA to submit to Congress a
strategic plan 1 year after enactment of the Committee bill and
every 4 years thereafter that would specify a 4-year forecast
for the demand for health care from VA by geographic location;
the capacity to provide health care at each facility; and the
capacity of care to be provided through community providers.
When developing the strategic plan, VA should consider access
guidelines and standards for quality developed under section
1703(h), as amended by section 101; market area assessments;
VA's needs in providing services for conditions that are
related to military service where there is limited community
expertise; consult with relevant stakeholders in the Federal
government, private sector, members of Congress, veterans
service organizations, and other policy experts; identify
emerging trends, issues, or potential opportunities that could
affect health care for veterans; develop recommendations for
short-term and long-term priorities for health care delivered
by VA; conduct a survey of veterans who have used the system to
gauge their satisfaction with VHA; and other matters VA
considers appropriate. Section 106(c) would define the
appropriate committees of Congress.
Sec. 107. Applicability of Directive of Office of Federal Contract
Compliance Programs.
Section 107 of the Committee bill, a freestanding original
provision, would set forth the applicability of the DOL Office
of Federal Contract Compliance Programs (hereinafter,
``OFCCP'') on provider agreements and agreements for state
homes, to mirror the applicability of contractors under the
TRICARE Program.
Background. Executive Order (hereinafter, ``E.O.'') 11246
charges DOL with protecting the rights of workers employed by
Federal contractors from discrimination on the basis of their
race, color, religion, sex, sexual orientation, gender
identity, or national origin with the responsibility of
ensuring equal employment opportunities.
In 2014, due to confusion over applicability of the E.O. on
TRICARE subcontractors under section 1072 of title 10, U.S.C.,
DOL established a 5-year moratorium on enforcement of the
obligations required of TRICARE subcontractors. During this
moratorium, DOL said it would work with other Federal agencies
to clarify the coverage of health care providers under Federal
statutes applicable to subcontractors.
Committee Bill. Section 107(a) would apply the same
moratorium on enforcement of obligations required of TRICARE
subcontractors to those entities that enter into VCAs, as
established under section 102 of the Committee bill, and
agreements for state homes found in section 1745(a) of title
38, U.S.C., as amended by section 103. Section 107(b) would
prohibit the directive described in subsection (a) from being
altered or rescinded before May 7, 2019. Section 107(c) would
define the TRICARE Program. It is the intent of the Committee
that DOL collaborate with VA to clarify the E.O.'s coverage of
health care providers.
Sec. 108. Prevention of certain health care providers from providing
non-Department health care services to veterans.
Section 108 of the Committee bill, a freestanding provision
derived from S. 1153, would require the Secretary to deny,
suspend, or revoke the eligibility of a non-VA health care
provider to participate in the community care program if the
provider was previously removed from employment by VA or had
their medical license revoked.
Background. While VA does have controls in place to ensure
that only high quality providers provide care to veterans in
the community, it is limited to checking the Department of
Health and Human Services' List of Excluded Individuals and
Entities and checking to ensure the providers have a current
and unrestricted license. While VA does take these steps to
ensure they only have high quality providers, VA does not take
the next step to check whether the provider has ever had their
license revoked. In addition, under the current practice at VA,
a former VA employee who was terminated from employment at VA,
but has not yet been reported to their state licensing board,
may still be able to provide care to veterans through contracts
or agreements with the VA.
Committee Bill. Section 108 would direct VA to deny,
suspend, or revoke the eligibility of a non-VA provider to
participate in VA's community care program if the provider was
previously removed from employment at VA or had their license
revoked. Specifically, section 108(a) would direct VA, 1 year
after enactment of the bill, to deny, revoke, or suspend a
provider's ability to provide care in the community if that
provider was removed from employment at VA because their
conduct resulted in their inability to deliver safe and
appropriate health care or violated the requirements of their
medical license that resulted in the loss of their license.
Section 108(b) would allow VA to deny, suspend, or revoke the
eligibility of a provider to participate in VA's community care
programs if the provider is under investigation by their state
medical licensing board and VA believes it is necessary to
protect the health, safety, and welfare of veterans. Section
108(c) would direct VA to deny, suspend, or revoke a provider's
ability to participate in VA's care in the community programs
if that provider has been suspended from service as a health
care provider in VA.
Section 108(d) would direct that, 2 years after enactment,
GAO submit a report to Congress on VA's implementation of this
section. The section directs that elements that should be
included in that report are the aggregate number of providers
denied, suspended, or revoked from delivering care in the
community; an evaluation on the impact on patient access to
care under VA's community care programs; an explanation of VA's
coordination with state medical boards and whether those boards
were involved in implementation of this section; and other
recommendations to complement eligibility criteria of VA health
care providers and health care providers eligible to provide
care through VA's community care programs. Section 108(e) would
define ``non-Department health care services'' to be services
provided under subchapter I of Chapter 17 of title 38, U.S.C.;
section 101 of P.L. 113-146; purchased through the Medical
Community Care Account; or purchased with funds deposited in
the Veterans Choice Fund.
SUBTITLE B--PAYING PROVIDERS
Sec. 111. Prompt Payment to Providers.
Section 111 of the Committee bill, an original provision,
would establish a new section 1703D of title 38, U.S.C., to
require VA to adhere to a specified prompt payment standard
when paying for hospital care, medical services, or extended
care services furnished by health care entities or providers
under this chapter.
Background. P.L. 113-146 included the sense of Congress
that VA should comply with the Prompt Payment Rule, section
1315 of title 5, Code of Federal Regulations, or any similar
regulation or ruling. The sense of Congress expressed that this
should apply to VA payment for health care to non-VA providers.
The law also required that VA implement a claims processing
system that complies with the Prompt Payment Act in chapter 39
of title 31, U.S.C.
A May 2016 GAO report, ``Proper Plan Needed to Modernize
System for Paying Community Providers,'' indicated that
according to VA FY 2015 data, it processed about 66 percent of
claims within 30 days or less. According to GAO, VHA did not
pay interest penalties on most late payments to community
providers until an Office of General Counsel opinion was issued
in October 2015, indicating that the Prompt Payment Act does
apply to VA care in the community claims.
Committee Bill. Section 111(a) would establish new section
1703D of title 38, U.S.C. Subsection (a) of this new section
would require VA to pay for hospital care, medical services, or
extended care services furnished under chapter 17 of title 38,
U.S.C., within 45 calendar days of receipt of a clean paper
claim or 30 calendar days of receipt of a clean electronic
claim. If a claim is denied, VA would be required to notify the
health care provider or entity regarding the reason for denial
and any additional information required within 45 calendar days
of denial of a paper claim and 30 calendar days of denial of an
electronic claim. These claims should be paid, denied, or
adjudicated within 30 calendar days from the receipt of the
requested information.
Under subsection (b) of new section 1703D of title 38,
U.S.C., health care providers or entities furnishing care or
services would be required to submit claims for payment to VA
not later than 180 days after the date on which the care was
furnished. Subsection (c) would require that sections 3729
through 3733 of title 31, U.S.C., apply to fraudulent claims
submitted to VA, and if the Secretary determines that a health
care entity or provider submitted a fraudulent claim, the
Secretary would be required to bar them from providing care
under this chapter.
Section (d) would require that any claim that has not been
denied with notice, made pending with notice, or paid to the
health care entity or provider by VA within the time periods
specified in subsection (a) be overdue. VA would be authorized,
consistent with chapter 39 of title 31, U.S.C., to require that
interest be paid on clean claims. Interest would be determined
in accordance with the rate established by the Secretary of the
Treasury under section 3902 of title 31 and published in the
Federal Register.
Section (d)(3) would require VA to annually submit to
Congress a report on payment of overdue claims under this
subsection, disaggregated by paper and electronic claims. The
reports would be required to include the amount paid in overdue
claims, disaggregated by the amount of the overdue claim and
the amount of interest paid on such overdue claim, the number
of overdue claims and the average number of days late each
claim was paid, disaggregated by VA facility and VISN.
Section (e) would require VA to deduct the amount of any
overpayment from payments due to a health care entity or
provider after making reasonable efforts to notify the provider
or entity of the right to dispute or request a compromise.
Section 1703D(f) of title 38, U.S.C., would require VA to
provide health care entities and providers furnishing care
under this chapter with a list of information required to
establish a clean claim. This information should be determined
after consultation with public and private sector health care
entities. Entities and providers must be notified of any
changes to the information required not later than 30 days
before the modifications take effect.
Section 1703D(g) of title 38, U.S.C., would require VA to
act through a non-VA entity to process claims for compensation
for hospital care, medical services, or extended care services
furnished by a health care entity under chapter 17 of title 38,
U.S.C. This could include a non-VA entity that is under
contract or agreement for the program established under section
1703(a) to title 38, U.S.C., or a non-VA entity that
specializes in such processing for other Federal agency health
care systems.
Section 1703D(h) of title 38, U.S.C., would require VA,
with 90 days of enactment, to submit to Congress a report on
the feasibility and advisability of adopting a funding
mechanism similar to what is utilized by other Federal agencies
to allow a contracted entity to act as a fiscal intermediary
for the Federal Government to distribute or pass through
Federal funds for certain hospital care, medical services, or
extended care services that are non-underwritten. VA may
coordinate with DOD, HHS, and the Department of the Treasury in
developing this report.
Under the Veterans Choice Program, third-party contracting
entities pay health care providers for the cost of care, and VA
reimburses the contracting entities. The Committee encourages
VA to examine whether this construct would be appropriate to
continue under the Veterans Community Care Program, as
established in Section 101 of the Committee bill.
Section 1703D(i) of title 38, U.S.C., would define ``clean
electronic claim'' as the transmission of data for purposes of
payment of covered health care expenses submitted to VA that
contains all of the required data elements necessary for
accurate adjudication. It would define ``clean paper claim'' as
a paper claim for payment of covered health care expenses
submitted to VA that contains all of the required data elements
necessary for accurate adjudication. This subsection would
define ``fraudulent claims'' as an intentional and deliberate
misrepresentation of a material fact or facts by a health care
entity or provider made to receive a claim that was not legally
payable to the provider. It would also define ``health care
entity or provider'' as any non-VA health care entity or
provider. Section 111(b) would provide for a clerical amendment
to insert 1703D in the table of sections.
In an effort to maximize VA's resources and time to provide
health care to veterans, the Committee recommends the VA
leverage industry partners--via third party administrators--to
process all non-VA health care claims. The Committee further
recognizes the VA's need to oversee claims processing
undertaken by non-VA employees. As such, the Committee
encourages the VA to develop policies allowing for prepayment
claim reviews which entails the random selection of claims for
manual review by VA to ensure the accuracy of claims
processing.
Sec. 112. Authority to pay for authorized care not subject to an
agreement.
Section 112 of the Committee bill, an original provision,
would add a new section to Subchapter IV of chapter 81 to
authorize the Secretary to compensate non-VA providers for
medical care they provided to a veteran, despite those
providers not being a party to the contract, agreement, or
other arrangement that furnishes that care.
Background. Through the course of providing medical care
for certain conditions, it is common for treating physicians to
collaborate with colleagues for care that is clinically
necessary. In the case of medical care for veterans, a non-VA
provider may not have a formal agreement with VA to provide
care to veterans but still operate in collaboration with an
entity or provider who does. For example, during a surgery, a
hospital may have a formal agreement with VA to provide care,
but the anesthesiologist may not, so he or she would generate a
separate bill for VA.
Committee Bill. Section 112(a) would provide the Secretary
with the authority to pay non-VA providers for care the
Secretary has determined is clinically necessary,
notwithstanding the absence of formalized contracts,
agreements, or other arrangements to provide such care. It also
would require the Secretary to take reasonable efforts to enter
into contracts, agreements, or other arrangements with such
providers to ensure that any future care is provided subject to
some type of formalized agreement. Section 112(b) would provide
for a clerical amendment to insert the item addressed in
Section 112(a) into the table of sections at the beginning of
chapter 81.
With this provision, the Committee intends for VA to pay
for non-VA medical care that the Secretary considers necessary
regardless of the relationship the non-VA providers have with
VA. The Committee also expects that after paying for such care,
VA would make reasonable attempts to establish formalized
agreements with those providers to ensure that future care they
provide is subject to such agreements.
Sec. 113. Improvement of authority to recover the cost of services
furnished for non-service-connected disabilities.
Section 113 of the Committee bill, an original provision,
would amend section 1729 of title 38, U.S.C., to authorize VA
to collect from a third party for care furnished to non-
veterans. It would also authorize VA to seek collections when
VA pays for care, rather than furnishes it, and remove
duplicative language regarding VA's authority to collect from
other health insurance for treatment of a non-service-connected
disability.
Background. Section 1729 of title 38, U.S.C. authorizes VA
to collect reasonable charges from a third party, to the extent
the veteran would be eligible, for care or services furnished
to veterans for a non-service-connected disability. In some
cases, VA pays for the care, but does not furnish it. In
addition, in some circumstances, VA furnishes care to non-
veterans, including certain Civilian Health and Medical Program
of the Department of Veterans Affairs (hereinafter,
``CHAMPVA'') beneficiaries and in emergency situations.
However, the current statute does not explicitly authorize VA
to collect reasonable charges related to the cost of care for
individuals who are not veterans.
Committee Bill. Section 113(a) would authorize VA to
collect from a third party for care furnished to non-veterans
by amending section 1729 of title 38, U.S.C., to refer to
``individuals'' instead of ``veterans.''
Section 113(b) would amend section 1729(a)(1) of title 38,
U.S.C., to authorize VA to seek collections when VA pays for
care, rather than furnishes it.
Section 113(c) would amend section 1729(a)(2)(D) to remove
duplicative language. Paragraph 2 of the subsection states that
VA's authorization to collect applies to a non-service-
connected disability that meets criteria established in the
following subparagraphs. Current subparagraph (D) restates that
the statute applies to veterans who do not have a service-
connected disability and who are entitled to care, or payment
of the expenses of care, under a health plan contract. The
Committee bill would eliminate the duplicative reference to
non-service-connected disability. It is the Committee's
understanding that this change simply removes duplicative
language and will have no impact on how VA interprets or
implements its authority to collect from third parties.
Sec. 114. Processing of Claims for Reimbursement Through Electronic
Interface.
Section 114 of the Committee bill, an original and
freestanding provision, would authorize VA to enter into an
agreement with a third-party entity to process health care
claims for reimbursement using an electronic interface.
Background. VA currently processes claims for non-VA care
and does not utilize an electronic interface. VA's current
process includes manual steps and does not include an online
portal for use by community providers to check the status of
their claims.
Committee Bill. Section 114 would authorize VA to enter
into an agreement with a third-party entity to utilize an
electronic interface to process claims for reimbursement for
health care provided under the laws administered by the
Secretary.
As noted in Section 111 of this report, the Committee
recommends the VA leverage industry partners to process all
non-VA health care claims. The Committee also encourages the VA
to develop policies allowing for prepayment claim review to
ensure the accuracy of claims processing.
SUBTITLE C--EDUCATION AND TRAINING PROGRAMS
Sec. 121. Education program on health care options.
Section 121 of the Committee bill, a freestanding provision
derived from S. 1279, would add a new section to title 38,
U.S.C., requiring the Secretary to develop and administer an
education program that informs veterans of their health care
options.
Background. Veterans have numerous options for how they
receive health care, including directly from VA providers at VA
facilities, from VA-reimbursed community providers, and from
providers of their choice through private insurance, Medicare,
Medicaid, the TRICARE program, IHS, and tribal health programs.
While VA offers a wide range of information on its website
aimed at informing veterans on their options for health care,
VA does not currently operate a program designed to educate
veterans about enrollment priority, financial obligations for
care, interaction between insurance and health care, and where
to direct complaints about health care received.
Committee Bill. Section 121(a) would direct VA to develop
and administer an education program to teach veterans about
their health care options through VA. The Committee intends
that VA ensure that veterans are provided clear guidance on how
to compare health care options available to them. The Committee
expects that during the implementation of the Caring for Our
Veterans Act, veterans will have questions comparing VA to
community care options for which they qualify. As such, the
Committee directs VA to provide guidance on how to interpret
and utilize access guidelines and standards for quality to
inform a veteran's health care decision.
Section 121(b) would direct that the required elements of
the training program include education about eligibility
criteria for care, enrollment priority groups, and financial
obligations for receiving services; teaching veterans about the
interaction between health insurance (including Medicare,
Medicaid, and the TRICARE program.) and VA health care; and
information about where to direct complaints about health care
received.
Section 121(c) would require the Secretary to ensure that
materials produced through the program are made available to
veterans who may not have Internet access. The Committee
expects VA to make a good-faith effort to communicate with
veterans through various mediums about their health care
options through VA.
Section 121(d) would require the Secretary to evaluate the
effectiveness of the education program and annually submit a
report to Congress on the findings of the evaluation.
Section 121(e) defines the terms ``Medicaid,''
``Medicare,'' and ``TRICARE program.''
Sec. 122. Training program for administration of non-Department of
Veterans Affairs health care.
Section 122 of the Committee bill, a freestanding provision
derived from S. 1279, would add a new section to title 38,
U.S.C., requiring the Secretary to establish a training program
for VA employees and contractors on how to administer non-VA
health care.
Background. VA has relied on non-VA entities to provide
health care to veterans for many years, but the reliance
increased after implementation of P.L. 113-146. Despite the
increasing use of non-VA providers to provide care for
veterans, there is no mechanism for providing VA employees and
non-VA providers with information they need to most effectively
treat veterans.
Committee Bill. With section 122, the Committee intends to
better educate VA employees and contractors to ensure veterans
have as positive a health care experience as possible.
Section 122(a) would direct which non-VA health care
programs would be covered as part of the proposed training
program. These include the program to reimburse for non-VA
emergency room care; the Veterans Community Care Program under
section 1703, as amended by section 101; and the management of
opioid prescriptions by non-VA providers pursuant to
improvements under section 131.
Section 122(b) would require the Secretary to evaluate the
effectiveness of the training program annually and submit the
findings of the evaluation to Congress.
Sec. 123. Continuing medical education for non-Department medical
professionals.
Section 123 of the Committee bill, a freestanding provision
which is derived from S. 1319, would establish a program to
provide continuing medical education to non-VA providers. The
program would be accredited in as many states as possible,
conforming to the rules and regulations of state medical
licensing agencies and medical credentialing organizations.
Background. Health care providers are usually required
under state law to meet education requirements in order to
retain their state medical license. For example, all but five
states require physicians to meet continuing medical education
requirements in cycles that range between annual and every 4
years. These requirements are intended to ensure that health
care providers stay current on medical technology, treatment
procedures, and medical research findings to provide the
highest quality care to their patients. Community health care
providers for veterans must ensure they meet state continuing
medical education requirements, sometimes by self-financing the
training.
Committee Bill. Section 123(a) would direct the topics to
be addressed within the proposed program. Specifically, the
program would include education on identifying and treating
mental and physical conditions of veterans and their family
members; VA's health care system; and any other matters the
Secretary considers appropriate.
Section 123(b) would establish parity between medical
professionals treating veterans outside VA and those within VA
on the continuing medical education material provided, in order
to support core competencies throughout the community.
Section 123(c) would direct how the program would be
administered. The Secretary would determine the curriculum and
number of credit hours to be provided, ensure the program would
be accredited in as many states as practicable, and be provided
at no cost to non-VA medical professionals. The Secretary would
also monitor utilization of the program, evaluate its
effectiveness, and report annually to Congress on findings in
these areas. Section 123(d) defines the term ``non-Department
medical professional.''
This section underscores the Committee's belief that
educated community health care providers are better positioned
to deliver high-quality care and services to veterans than
providers who lack an understanding of the specific needs of
veterans. The Committee also recognizes that by providing
continuing medical education at no cost, community providers
may be more likely to work with VA to provide care and services
to veterans.
SUBTITLE D--OTHER MATTERS RELATING TO NON-DEPARTMENT OF VETERANS
AFFAIRS PROVIDERS
Sec. 131. Establishment of processes to ensure safe opioid prescribing
practices by non-Department of Veterans Affairs health care
providers.
Section 131 of the Committee bill, a freestanding provision
derived from S. 2134, would establish the processes by which VA
ensures that non-VA health care providers participating in the
Community Care program are safely prescribing opioids.
Background. P.L. 114-198, the Jason Simcakoski Memorial and
Promise Act (hereinafter, ``P.L. 114-198''), amended section
1701 of title 38, U.S.C., to modify the agency's opioid
prescribing guidelines, increasing oversight and accountability
in VA's pain management and prescription services for veterans.
Despite these efforts, the prescribing methods of contract
providers may not meet the same rigorous safety standards. A
July 2017 VA Office of Inspector General (hereinafter, ``OIG'')
report on opioid prescribing by community providers found that
many are not subject or do not adhere to VA's opioid safety
reforms. The report also found that VA was not consistently
tracking veteran's prescription history and information from
community providers.
Committee Bill. Section 131 would direct the Secretary to
create processes and guidelines to ensure community providers
adhere to the same standards as VA in safely prescribing
opioids. Section 131(a) would direct the Secretary to certify
that community providers review the agency's guidelines for
prescribing opioids as set forth by P.L. 114-198. Section
131(b) would direct the Secretary to establish a process for
information sharing with community providers to include
veterans complete prescription history on their electronic
health records.
Section 131(c) would require all providers participating in
the new VA Community Care Program to submit opioid
prescriptions to VA for prior authorization or directly to a VA
pharmacy for dispensing, and would require VA to record and
monitor the prescriptions. The subsection includes exceptions
in cases where there is an immediate medical need for the
prescription or when obtaining a prescription at a VA pharmacy
would impose undue hardship on the veteran. The Secretary is
required to report quarterly to Congress on community
providers' compliance and noncompliance. It is the Committee's
intent that this section serve as an oversight measure by
directing the Secretary to monitor and report community
providers who are not following the proper safety guidelines
and regulations for dispensing opioids.
Section 131(d) would ensure that VAMC and VISN directors
have authority to take appropriate action against community
providers they believe are using prescribing practices
inconsistent with the standards of appropriate and safe care.
Subsection (e) would provide the authority to deny or revoke
eligibility of non-VA providers based on their opioid
prescribing practices. The Committee believes that opioid
prescribing among community providers must be closely monitored
and regulated, and that these sections would provide the agency
with the authority and tools to evaluate and manage contracts
with community providers based on criteria to meet safety
standards. Subsection (f) would provide a definition for a
covered health care provider as a non-VA provider who provides
health care to veterans under laws administered by VA.
Sec. 132. Improving information sharing with community providers.
Section 132 of the Committee bill, an original provision,
would amend the existing provision in section 7332(b)(2)(H)
regarding VA's ability to disclose protected health information
to community providers and create a new exception in
subparagraph (I) that would allow VA to share records with
third parties to recover or collect reasonable charges for care
provided.
Background. Under section 7332 of title 38, U.S.C., VA must
keep confidential, with certain exceptions, medical records
connected to patient activities associated with substance use
disorders, human immunodeficiency virus infections, and sickle
cell anemia.
Committee Bill. Section 132 would amend section 7332(b)(2)
of title 38, U.S.C., by striking subparagraph (H) to insert
three new paragraphs. It would add a new paragraph (H)(i)
providing that the Secretary could share records with non-VA
providers for the purpose of furnishing hospital care, medical
services, or extended care services to patients.
Section 7332(b)(2), as amended, would replace the existing
paragraph (H)(ii) with a new paragraph providing that the
entity to which such a protected record is disclosed may not
disclose to another party or use the protected record for a
purpose other than that for which the disclosure was made.
Section 7332(b)(2) would add a new paragraph (I) providing
authority to VA to disclose medical records for purposes of
recovering or collecting reasonable charges from the patients'
other health plan contracts or other responsible third parties
for care furnished by VA to a patient for a non-service
connected disability.
Sec. 133. Competency standards for non-Department of Veterans Affairs
health care providers.
Section 133 of the Committee bill, a freestanding original
provision, would require the Secretary to establish competency
standards and requirements for non-VA providers that treat
injuries or illnesses in clinical areas that VA has a special
expertise.
Background. The 2016 bi-partisan Commission on Care final
report recognized,
. . . the VA health care system has valuable strengths,
including some unique and exceptional clinical programs
and services tailored to the needs of the millions of
veterans who turn to VA for care. For example, VHA's
behavioral health programs, particularly with their
integration of behavioral health and primary care, are
largely unrivalled, and profoundly important to many
who have suffered from the effects of battle and for
whom VHA is a safety net.
With an increase in medical services provided by non-VA
providers, there is a concern that community providers may not
be able to provide the same level and quality of care,
particularly in treating the unique nature of the injuries and
illnesses among veterans.
Committee Bill. Section 133(a) would direct VA to establish
competency standards and requirements for non-VA providers.
These standards and requirements would be for clinical areas
for which VA has clinical expertise, such as traumatic brain
injury, military sexual trauma, and post traumatic stress
disorder. Section 133(b) would require that these standards and
requirements be met, through training or other means
established by the Secretary, as a condition upon entering into
a contract under the Veterans Community Care Program.
With this provision, it is the intent of the Committee to
require the Secretary to ensure community providers meet the
same competency and quality standards of VA.
SUBTITLE E--OTHER NON-DEPARTMENT HEALTH CARE MATTERS
Sec. 141. Plans for Use of Supplemental Appropriations Required.
Section 141 of the Committee bill, a freestanding original
provision, would direct the Secretary to provide additional
information to Congress when the Secretary requests funding
outside the standard budget process.
Background. VA has demonstrated a lack of ability to
effectively anticipate funding requirements and utilization
timelines for their community care programs, most notably for
the Veterans Choice Program as created in P.L. 113-146. In mid-
2017, with little notice provided to Congress, VA provided
guidance to VA medical facilities that Choice-related community
care would need to be triaged as a result of dwindling money in
the Veterans Choice Fund. As a result, P.L. 115-46, the VA
Choice and Quality Employment Act of 2017 (hereinafter, ``P.L.
115-46''), authorized and appropriated $2.1 billion into the
Veterans Choice Fund in mid-August, to prevent a delay in care
for veterans. More recently, VA notified Congress that the $2.1
billion, which VA believed would take 6 months to exhaust,
would be expended in mid-January 2018.
Committee Bill. Section 141 would require that when the
Secretary submits a request for funding outside the standard
annual budget process, it must come 45 days prior to the date
that any veteran program would be impacted, and must include a
justification for the request, including a detailed business
plan for execution and timeline for how long the additional
funding is projected to last. Further, the Secretary must
certify that the request was developed using a sound actuarial
analysis. While the Committee is supportive of providing
community care to veterans, the Committee also expects VA to
utilize taxpayer dollars responsibly, and make appropriate and
sufficient requests through the standard Federal budgeting
process.
Sec. 142. Veterans Choice Fund flexibility.
Section 142 of the Committee bill, an original provision,
would amend section 802 of P.L. 113-146 to authorize VA,
beginning in FY 2019, to use remaining amounts in the Veterans
Choice Fund to pay for any health care services under Chapter
17 of title 38, U.S.C., at non-VA facilities or through non-VA
providers furnishing care in VA facilities.
Background. Section 802 of P.L. 113-146 authorized the
Veterans Choice Fund to fund the Veterans Choice Program.
Section 802 authorized and appropriated $10 billion for the
Veterans Choice Fund to be available until expended for the
Veterans Choice Program. In 2017, P.L. 115-46 authorized and
appropriated $2.1 billion into the Veterans Choice Fund, to
remain available until expended. When VA indicated to the
Committee that the $2.1 billion in the Veterans Choice Fund
would be expended in mid-January 2018. Congress appropriated an
additional $2.1 billion in P.L. 115-96, a bill to make
continuing appropriations (hereinafter, ``P.L. 115-96'').
Section 402 of the Committee bill would provide an additional
$4 billion for the Veterans Choice Fund.
Committee Bill. Section 142 would authorize the Secretary,
beginning in FY 2019, to use the remaining funds in the
Veterans Choice Fund to pay for any health care services
described in Chapter 17 of title 38, U.S.C., provided at non-VA
facilities or through non-VA providers in VA facilities. The
Committee intends the funds in the Veterans Choice Fund to be
used for non-Veterans Choice Program care only after the new
community care program established under section 101 of the
Committee bill is fully implemented.
Sec. 143. Sunset of Veterans Choice Program.
Section 143 of the Committee bill, an original provision,
would amend section 101(p) of P.L. 113-146 to end the
Secretary's authority to administer the Veterans Choice Program
after December 31, 2018.
Background. Section 101 of P.L. 113-146 established the
Veterans Choice Program. Section 101(p) authorized the program
until funds appropriated for the Veterans Choice Program were
expended or 3 years after the date of enactment of the law.
Section 2 of P.L. 115-26, an Act to amend the Veterans Access,
Choice, and Accountability Act of 2014, eliminated that end
date.
Committee Bill. Section 143 would remove the Secretary's
authority to furnish care and services under section 101(p) of
P.L. 113-146 after December 31, 2018.
Sec. 144. Conforming amendments.
Section 144 of the Committee bill, an original provision,
would amend existing authorities to account for changes made by
section 101 of the bill to consolidate and create the Veterans
Community Care Program.
Background. VA currently uses several different authorities
within title 38, U.S.C., to provide care for veterans in the
community, such as sections 8111 and 8153. In addition, Section
101 of the Committee bill would amend section 1703 of title 38,
U.S.C., and section 102 of the Committee bill would provide VA
with new statutory authority to enter into provider agreements.
Certain sections of law referencing section 1703 would need to
be amended to reflect the new authority.
Committee Bill. Section 144 would make conforming
amendments to other sections of the United States Code.
Specifically, section 144(a)(1) would amend the authorities
allowing VA to provide outpatient dental services at non-VA
facilities; allowing VA Readjustment Counseling Centers to
enter into contracts to provide care; and clarify the
facilities referenced in VA's burial plot allowance. Section
144(a)(2) would amend the Social Security Act to ensure the
proper reference regarding hospitals that receive payments from
the Medicare program if those hospitals provide inpatient care
to veterans for procedures that the local VA facility is not
able to provide. Section 144(a)(3) would amend P.L. 103-466,
the Veterans Benefits Improvements Act of 1994, to ensure the
appropriate reference to continue VA's authority to use
contracts to diagnose or treat veterans with Gulf War Illness.
Section 144(b) would establish the effective date for
subsection (a) as the date described in section 101(b).
TITLE II--IMPROVING DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE DELIVERY
SUBTITLE A--PERSONNEL PRACTICES
PART I--ADMINISTRATION
Sec. 201. Licensure of health care professionals of the Department of
Veterans Affairs providing treatment via telemedicine.
Section 201 of the Committee bill, which is derived from
S. 925, would add a new section to title 38, U.S.C., providing
VA with authority for its covered health care professionals to
provide health care services to a patient no matter where the
provider or patient is located using telemedicine services.
Background. Telemedicine has proven to help VA deliver
health care services to veterans located in areas where VA or
private sector health care providers may be unavailable or for
veterans who are, for whatever reason, unable to travel to a
health care provider. Therefore, telemedicine has the potential
to enable VA to provide timelier, convenient service to
veterans. Codifying VA's ability to provide such services via
telemedicine, whether the veteran or provider is located in the
same or different states, whether or not they are in a Federal
building, the veteran's home, or VA facility, will aide VA in
using its resources most efficiently. There exists no explicit
authorization for the provision of telemedicine services by VA.
Under section 7301 of title 38, U.S.C., VA is charged with
providing medical and hospital services for the medical care
and treatment of veterans. Under section 1722B of title 38,
U.S.C., VA may waive copayments for veterans who receive
telehealth and telemedicine services under the laws
administered by the Secretary.
Committee Bill. Section 201(a) would amend chapter 17 of
title 38, U.S.C., to add a new section 1730B regarding the
licensure of covered health care professionals to provide
telemedicine services. Section 1730B(a) would provide covered
VA health care professionals with the ability to practice in
any state, notwithstanding the location of the health care
provider or the patient, when the treatment is occurring by
telemedicine.
Section 1730B(b)(1) would require that the ``covered health
care professional'' eligible to provide services under Section
1730B be an employee of the VA appointed under title 38 or
title 5. Section 1730B(b)(2) would require that the ``covered
health care professional'' eligible to provide services under
Section 1730B be authorized by the Secretary to provide health
care under Chapter 17 of title 38, U.S.C. Section 1730B(b)(3)
would require that the ``covered health care professional''
eligible to provide services under Section 1730B be required to
adhere to all of VA's standards of quality related to the
provision of medicine. Section 1730B(b)(4) would require that
the ``covered health care professional'' eligible to provide
services under section 1730B be required to hold ``an active,
current, full, and unrestricted license, registration, or
certification in a State to practice the health care profession
of the health care professional.''
Section 1730B(c) would provide that neither the covered
health care professional nor the patient are required to be
located in a Federal Government facility during the health care
services conducted by telemedicine. Section 1730B(d)(1) would
provide that this section's provisions supersede any and all
laws of any State that are inconsistent with the section.
Section 1730B(d)(2) would provide that no State may take action
to deny or revoke the license or other credential of a covered
health care professional because the professional has engaged
or intends to engage in an action covered by subsection (a).
Section 1730B(e) would clarify that this bill is not intended
to remove, limit, or otherwise affect a covered health care
professional's obligations under the Controlled Substances Act
(21 U.S.C. 801 et seq.).
Section 201(b) bill would amend the table of sections at
the beginning of chapter 17 of title 38, U.S.C., to add the new
section 1730B.
Finally, section 201(c) would require VA, not later than 1
year after the earlier of either the date services under the
new section begin or the regulations to carry out the section
are promulgated, submit to Congress a report on veteran and
provider satisfaction with the program, statistics on the
program's use, as well as any savings to VA from the program's
use.
As VA noted in its proposed rule 82 FR 45756, ``to furnish
care to all beneficiaries and use its resources most
efficiently, VA needs to operate its telehealth program with
health care providers who will provide services via telehealth
to beneficiaries in States in which they are not licensed,
registered, certified, or located, or where they are not
authorized to furnish care using telehealth. Currently, doing
so may jeopardize these providers' credentials, including fines
and imprisonment for unauthorized practice of medicine, because
of conflicts between VA's need to provide telehealth across the
VA system and some States' laws or licensure, registration,
certification, or other requirements that restrict or limit the
practice of telehealth.'' Additionally, consonant with the
definition of ``State'' in subsection 101(20) of title 38,
U.S.C., no political subdivision of a state may attempt to
abrogate the authority granted in subsection 1730B.
The Committee does not intend for this section to create
any coverage for non-VA employed health care providers. They
are not subject to the same rigorous oversight and
accountability standards that VA-employed health care
professionals are.
The Committee supports the use of this authority,
particularly for the purposes of addressing the mental health
needs of veterans and preventing veteran suicide. Further
development of VA's telemental health delivery hubs throughout
the Nation should proceed apace to offer veterans more
convenient treatment options. To further the goals of this
Committee bill, we urge VA to ensure that covered health care
providers can maximally benefit from telework or other suitable
work arrangements.
The Committee additionally believes that rural veterans are
particularly suited to benefit from this authority. However,
the Committee is aware that there are significant barriers to
rural veterans taking advantage of this authority, particularly
as a result of the lack of a robust Internet or wireless
infrastructure in many parts of the country. To that end, the
Committee calls on VA to work with partners in the community,
such as veterans service organizations or local governments, to
find innovative ways to help these veterans benefit from this
authority. VA should examine whether these organizations could
establish veteran-cost-free telemedicine delivery areas in
their facilities, particularly for veterans who lack access to
Internet or wireless services, as a way to help maximize the
use of the services and help veterans feel comfortable with
this modality of care.
Sec. 202. Role of podiatrists in Department of Veterans Affairs.
Section 202 of the Committee bill, which is derived from
S. 1871, would amend chapter 74 of title 38, U.S.C., by adding
a new section 7413 to make podiatrists eligible for any
supervisory position in VHA to the same degree that a physician
appointed under section 7401(1) is eligible and would increase
the pay grade of podiatrists to match the compensation of VHA
surgeons, physicians, and dentists. This section would require
the Secretary to establish standards to ensure that specialists
appointed to supervisory VHA positions do not provide direct
clinical oversight for purposes of peer review or practice
evaluation for providers of other clinical specialties.
Background. The Committee is concerned VA is experiencing
recruitment and retention issues for podiatrists. According to
a February 2017 VA white paper on podiatry pay, the podiatrist
compensation package has remained unchanged since 1976, except
for those changes that include adjustments for basic pay and
locality rates. VA indicated there is a growing health care
demand for primary and specialty podiatric services, especially
among veterans suffering from polytraumatic injuries and spinal
cord injuries, in addition to the approximately 1.8 million
veterans who are at risk of major foot wounds, infection, and
amputation. According to CBO, VA employs about 400 podiatrists
nationwide at an average salary of $130,000. Under this
section, CBO anticipates that the base salary for podiatrists
would increase by about 15 percent to $150,000 and VA would be
able to hire an additional 30 podiatrists because the increased
salary would make working for VA more attractive.
Committee Bill. Section 202(a) would make a podiatrist
eligible for any supervisory position to the same degree as a
VHA physician. This section requires the Secretary to establish
standards to ensure that specialists appointed to supervisory
VHA positions do not provide direct clinical oversight for
purposes of peer review or practice evaluation for providers of
other clinical specialties. Section 202(b) increases the pay
grade of podiatrists to match the compensation of other VHA
surgeons, physicians, and dentists. The Committee expects these
changes to aid in the recruitment and retention of podiatrists
at VHA.
Sec. 203. Modification of treatment of certified clinical perfusionists
of the Department.
Section 203 of the Committee bill, an original provision,
would amend sections 7401 and 7455 of title 38, U.S.C., to
include certified clinical perfusionists in the list of
excepted positions and convert such positions to full title 38
status.
Background. Perfusionists are members of a surgical team
providing highly specialized care during open heart surgery
through the operation of the cardiopulmonary bypass machine
(heart-lung machine). Currently, perfusionists are designated
as title 38 hybrid employees and fall under the medical
instrument technician qualification standard which limits their
General Schedule level and salary. VA has experienced
difficulty recruiting and retaining perfusionists, requiring
some VAMCs to contract for perfusionist services.
Committee Bill. Section 203 would amend sections 7401 and
7455 of title 38, U.S.C., to provide certified clinical
perfusionists in the list of excepted positions and convert
such positions to full title 38 status to assist in the
recruitment and retention of highly skilled perfusionists.
Sec. 204. Amending statutory requirements for the position of the Chief
Officer of the Readjustment Counseling Service.
Section 204 of the Committee bill, which is derived from
S. 1325, would amend section 7309(b)(2) of title 38, U.S.C., to
remove the requirement that the Chief Officer of the RCS have
at least 3 years of experience in providing and administrating
direct counseling services or outreach service that is
specifically within RCS.
Background. Section 7309(b)(2) of title 38, U.S.C.,
provides the statutory requirements for an individual to be
eligible for hiring as the Chief Officer of the RCS.
Committee Bill. Section 204 would amend section 7309(b)(2)
of title 38, U.S.C., by removing the requirement that the Chief
Officer of the RCS have provided counseling or outreach as well
as been an administrator in the RCS, specifically. No changes
are made to the other requirements that the individual have
advanced degrees in mental health or social work, have 3 years
of experience providing direct counseling services and 3 years
administering such services, meet the quality standards and
requirements of VA, and be a combat veteran of the Armed
Forces.
VA has stated that the pool of applicants for the position
of RCS Chief Officer has been unhelpfully narrowed by the
requirements of sections 7309(b)(2)(B) and (C). This has led to
extended periods without a permanent Chief Officer of the RCS.
As noted by the February 2017 Department of Veterans Affairs
Advisory Committee on the Readjustment of Veterans' Annual
Report, the Chief Officer position had been vacant from
December 31, 2012 until May 2016. While the bill removes the
requirement that the individual have a minimum of 3 years of
employment specifically in the RCS as a direct counselor and 3
years as an administrator, it is the Committee's expectation
that VA will continue to look to promote from within and ensure
the unique culture and services provided by RCS flourish in the
future. The Committee will conduct oversight over the
administration of the RCS to ensure that the readjustment needs
of combat veterans and other eligible veterans and their family
members are met appropriately. Key to that is the promotion of
the psychosocial readjustment counseling offered at RCS
facilities in combination with the combat experience required
of its employees; the Chief Officer of RCS must be fully
experienced in this culture.
Sec. 205. Technical amendment to appointment and compensation system
for directors of medical centers and directors of Veterans
Integrated Service Networks.
Section 205 of the Committee bill, an original provision,
would amend section 7404(d) of title 38, U.S.C., to make an
exception for increasing the compensation scale and raises for
VAMC directors and directors of VISNs.
Background. P.L. 115-41, the Department of Veterans Affairs
Accountability and Whistleblower Protection Act of 2017
(hereinafter, ``Accountability Act''), allowed VA to directly
appoint VAMC directors and directors of VISNs. While the bill
included a conforming amendment to section 7404(a) of title 38,
U.S.C., the bill did not include a conforming amendment to
section 7404(d) of title 38, U.S.C., to allow for higher pay
for these individuals.
Committee Bill. Section 205 would amend section 7404(d) of
title 38, U.S.C., to make an exception for increasing the
compensation scale and raises for VAMC directors and directors
of VISNs.
Sec. 206. Identification and staffing of certain health care vacancies.
Section 206 of the Committee bill, a freestanding original
provision, would require the Secretary to identify and fully
staff certain VA vacancies and submit a report within 210 days
on progress made in filling such vacancies.
Background. Because of its decentralized structure, VHA is
unable to determine a point-in-time count of VA mental health
vacancies and primary care and mental health vacancies in the
VA's PACTs. This information is essential for VHA to be able to
address any systematic understaffing problems that may exist
within service lines across VISNs or at certain types of VAMCs.
Also, despite VA's knowledge of health care provider vacancies
in the past, VHA has been slow to fill them.
Committee Bill. Section 206(a) would require the Secretary
to identify and fully staff within 180 days VA mental health
vacancies, as well as primary care and mental health vacancies
in VA PACTs.
Section 206(b) would require the Secretary to submit a
report to Congress within 210 days specifying whether VA has
complied with the requirements of this section and, if not, how
many vacancies remain, and why VA was unable to fill them.
With this provision, the Committee expects VA to
aggressively address understaffing issues before they reach
crisis levels.
Sec. 207. Department of Veterans Affairs personnel transparency.
Section 207 of the Committee bill, a freestanding original
provision, would require the Secretary to make staffing
capacity information and data, such as vacancies and active job
postings, publicly available on a VA website.
Background. P.L. 113-146 requires the OIG to annually
determine the five occupations within VHA for which there are
the largest staffing shortages. A May 2014 OIG report, that
preceded the requirements of P.L. 113-146, addressing ongoing
concerns on VA's scheduling practices and excessive wait times
acknowledged staffing shortages as one of many contributing
factors. Concerns on inadequate staffing and hiring practices
have been identified in OIG reports dating back to 2013. To
date, the OIG has conducted its fourth report as required by
P.L. 113-146 and its most recent analysis from September 2017
determined that for critical need occupations, a significant
percentage of the total gains continues to be offset by staff
losses and that VHA still does not have adequate, comprehensive
operational staffing models for critical need occupations.
Committee Bill. Section 207 would require the Secretary to
make staffing capacity information publicly available on a VA
website. This provision would also require the information to
be updated monthly, a semi-annual OIG review, and an annual
report to Congress. The Committee intends that this information
will assist VA in filling vacancies and provide greater
transparency for stakeholders and Congress into challenges VA
is having in recruiting and retaining personnel.
Sec. 208. Program on establishment of peer specialists in Patient
Aligned Care Team settings within medical centers of Department
of Veterans Affairs.
Section 208 of the Committee bill, a freestanding
provision, which is derived from S. 1873, would require the
Secretary to carry out a program to establish peer specialists
in PACTs at VAMCs.
Background. VA has used peer specialists to assist veterans
who are in treatment for mental health and substance abuse
disorders. Peer specialists are veterans who are VA employees
that serve as part of a care management team that promotes
veterans' recovery by sharing their own recovery stories,
providing encouragement, and teaching skills needed for
successful recovery. The limited authority for utilizing the
peer support model in the primary care setting has hindered the
VA's ability to effectively engage veterans who would benefit
from mental health or substance use treatment services. The
stigma associated with veterans seeking care for mental health
and substance use may result in veterans missing a key entry
point to the effective VA peer support model of care.
Committee Bill. Section 208(a) would require the Secretary
to establish a program to place not fewer than two peer
specialists in PACTs at VAMCs to promote mental health,
behavioral health, and substance use disorder care in primary
care settings.
Section 208(b) would require the Secretary to establish the
program in not fewer than 25 VAMCs by December 31, 2018, and 50
VAMCs by December 31, 2019.
Section 208(c)(1) would require the Secretary to locate the
program in not fewer than 5 VAMCs that are designated as
polytrauma centers and not fewer than 10 VAMCs that are not
designated as polytrauma centers.
Section 208(c)(2) would require the Secretary to consider
the feasibility and advisability of selecting VAMCs to operate
the program in areas that are rural or underserved, not in
close proximity to an active duty military installation, and
different geographic locations, such as census tracts
established by the Bureau of the Census.
Section 208(d) would require the Secretary to ensure that
in carrying out the program the needs of female veterans are
specifically considered and addressed and female peer
specialists are made available to female veterans treated at
each location.
Section 208(e) would require the Secretary to consider ways
in which the peer specialists at each location can conduct
outreach to community health care providers who are providing
services to veterans as well as the veterans receiving
services.
Section 208(f)(1) would require the Secretary to submit to
Congress a report on the pilot program no later than 180 days
after commencement and every 180 days thereafter until the
Secretary determines the program is being carried out at the
last location selected under subsection 208(c). The report
would be required to include the findings and conclusions of
the Secretary with respect to the program, an assessment of the
program's benefits to veterans and family members, and an
assessment of the effectiveness of outreach described in
subsection 208(e).
Section 208(f)(2) would require the Secretary to submit to
Congress a final report on the pilot program no later than 180
days after the Secretary determines the program is being
carried out at the last location selected under subsection
208(c). The report would detail the Secretary's recommendations
as to the feasibility and advisability of expanding the program
to additional locations.
With section 208, the Committee intends to examine the
value of utilizing the peer support model in primary care
settings.
Sec. 209. Pilot program on increasing the use of medical scribes to
maximize the efficiency of physicians at medical facilities of
the Department of Veterans Affairs.
Section 209 of the Committee bill, a freestanding
provision, which is derived from S. 113, would require VA to
establish a pilot program to evaluate the use of medical
scribes by VA physicians.
Background. The Joint Commission, which is a non-profit
organization that accredits and certifies health care
organizations, including VA, defines a scribe as ``an
unlicensed person hired to enter information into the
electronic medical record or chart at the direction of a
physician or practitioner . . . Scribes are used most
frequently, but not exclusively, in emergency departments where
they accompany the physician or practitioner and record
information into the medical record, with the goal of allowing
the physician or practitioner to spend more time with the
patient and have accurate documentation.\3\''
---------------------------------------------------------------------------
\3\The Joint Commission, https://www.jointcommission.org/
standards--information/jcfaq details.aspx?StandardsFAQId=1206, accessed
December 11, 2017.
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According to the Journal of the American Board of Family
Medicine, ``Available evidence suggests medical scribes may
improve clinician satisfaction, productivity, time-related
efficiencies, revenue, and patient--clinician interactions.''
However, because a significant amount of research on the use of
medical scribes has not been conducted, there are limits on the
reliability of the evidence from the small number of studies
that have been done.\4\
---------------------------------------------------------------------------
\4\``The Use of Medical Scribes in Health Care Settings: A
Systematic Review and Future Directions.'' Cameron G. Shultz, PhD, MSW
and Heather L. Holmstrom, MD; May-June 2015; http://www.jabfm.org/
content/28/3/371.full.
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Committee Bill. Section 209(a) of the Committee bill would
require VA to carry out a pilot program to increase the use of
medical scribes to maximize the efficiency of physicians at VA
medical facilities.
Sections 209(b) and 209(c) would require VA to carry out
the pilot program for 18 months at not fewer than five VA
medical facilities at which the Secretary has determined have a
high volume of patients or that are located in and at which the
Secretary has determined there is a shortage of physicians and
the physicians have high caseloads.
Section 209(d) would require VA to enter into a contract
for purposes of carrying out the pilot with one or more
appropriate nongovernmental entities. An appropriate
nongovernmental entity is defined as an entity that trains and
employs professional medical scribes who specialize in the
collection of medical data entry into electronic health
records.
Section 209(e) would require VA to collect data on the
pilot program in an effort to determine its effectiveness in
increasing the efficiency of VA physicians. This data should
include the average wait time for a veteran to receive care
from a physician prior the pilot's implementation and the
average wait time for such care after implementation; the
average number of patients that such physician is able to see
daily prior to implementation and the average number of
patients such physician is able to see daily after
implementation; the average amount of time such physician
spends daily on documentation prior to implementation and the
average amount of time such physician spends on documentation
daily after implementation; the satisfaction and retention
scores of each such physician prior to the pilot's
implementation and after; the patient satisfaction scores for
each such physician prior to the pilot's implementation and
after; and the patient satisfaction scores for their health
care experience both before and after the pilot's
implementation.
Section 209(f) would require VA to submit to Congress a
report on the pilot program no later than 180 days after
commencement and every 180 days thereafter for the duration of
the pilot program. The report would be required to include the
number of VA medical facilities participating in the pilot and
an assessment of the effects that participation in the pilot
program has had on each medical facility, including maximizing
the efficiency of physicians at each facility, reducing average
wait times for appointments, improving access of patients to
electronic medical records, mitigating physician shortages by
increasing the productivity of physicians, all data collected
under subsection (e), and recommendations from the Secretary
with respect to extending or expanding the pilot program.
Section 209(g) would define medical scribe as a member of
the medical team hired and trained specifically and exclusively
to perform documentation in an electronic health record to
maximize the productivity of a physician.
This pilot is an effort to continue to evaluate ways to
increase physician efficiency and better serve veterans.
Increasing physician efficiency could especially benefit
medical facilities that have a shortage of physicians and those
physicians with a high caseload.
Sec. 210. Sense of Congress regarding Department of Veterans Affairs
staffing levels.
Section 210 of the Committee bill, a freestanding original
provision, would express the Sense of Congress that VA should
make resolution of staffing shortages a top priority.
Background. While VA has acknowledged staffing shortages as
a significant problem in the past, those shortages persist
while VA initiates other organizational efforts.
Committee Bill. Section 210(a) would describe Congressional
findings that VA needs to fill at least 35,000 positions and
that not filling those positions cause delays in veterans
receiving benefits and services. Section 210(b) would express
the Sense of Congress that VA should prioritize filling vacant
positions.
It is not clear to the Committee that VA has taken the
issue of staffing shortages seriously. This provision
emphasizes the importance with which the Committee believes VA
should be treating this fundamental problem, as the health of
millions of veterans depends on sufficiently staffed health
care facilities.
PART II--EDUCATION AND TRAINING
Sec. 211. Graduate Medical Education and Residency.
Section 211 of the Committee bill, a freestanding original
provision, would require VA to increase the number of GME
positions by up to 1,500 positions at facilities that include
non-VA facilities.
Background. Section 7302 of title 38, U.S.C., requires VA
to carry out education and training programs, including medical
residency programs. According to VA, it has the largest
education and training program for health professionals in the
United States. VA indicates that an estimated 70 percent of
physicians in the United States have received training from VA.
P.L. 93-82, the Veterans Health Care Expansion Act of 1973,
authorized VA to enter into agreements with academic affiliates
to administer resident salary and benefits. It also authorized
VA to only reimburse academic affiliates for the cost of the
time period in which the resident is training at a VA facility.
P.L. 113-146 required VA to increase its number of GME
residency positions by up to 1,500 over a 5-year period,
beginning in 2015. P.L. 114-315, the Jeff Miller and Richard
Blumenthal Veterans Health Care and Benefits Improvement Act of
2016, extended the timeline by an additional 5 years. The law
requires that when adding these positions, VA prioritize
primary care, mental health, and other specialties determined
appropriate, while also establishing these new positions in VA
facilities without a GME program or in communities with a high
concentration of veterans.
Committee Bill. Section 211(a) would require VA to increase
the number of GME residency positions by up to 1,500 in the 10-
year period beginning on the date of enactment. VA would be
authorized to add these positions not only at VA facilities,
but also at facilities operated by an Indian tribe, tribal
organization, or IHS; an FQHC; a community health center; a DOD
facility; or another health care facility the Secretary
considers appropriate. VA would be authorized to pay stipends
and benefits to these residents, regardless of whether they are
placed in a VA facility. When determining residency positions,
the Secretary would be required to consider several factors,
including whether the facility is located in a rural location,
whether the local community is medically underserved, and the
ratio of veterans to VA health care providers in the area
surrounding a facility. When determining specialties to be
included in the residency positions, the Secretary would also
be required to consider the types of specialties that improve
quality and coverage of services to veterans and whether the
specialty is included in VA's most recent staffing shortage
determination.
Section 211(b) would require residents to submit
applications to VA with an agreement to commit to a period of
obligated service in return for stipend and benefit support.
Section 211(c) would require VA to notify individuals in
writing upon their acceptance into the program.
Section 211(d) would require the residents and VA to have
an agreement in writing regarding the terms of the residency,
including by requiring a service obligation equal to the number
of years of stipend support.
Section 211(e) would authorize VA to prescribe conditions
of employment, including training and amount and terms of pay.
Section 211(f) would require residents to fulfill a period
of obligated service as a full-time employee of VA in the
clinical practice of the participant's profession or in another
health-care section assigned by VA. VA would be required to
notify individuals of their commencement date of service no
later than 60 days prior.
Section 211(g) would establish penalties for those who fail
to accept payment or instruct the educational institution in
which the person is enrolled not to accept payment for a
residency agreed to under subsection (d) and for residents who
fail to fulfill their service obligation as a result of
dismissal for disciplinary reasons, voluntary termination of
residency, or loss of state license, registration, or
certification to practice their health care profession.
Section 211(h) would authorize VA to recover funds,
according to the specified formula, from those who breach their
agreement.
Section 211(i) would require VA to submit to Congress an
annual report detailing the positions filled under this
section, as well as the location, associated academic
affiliate, and any challenges faced in filling the positions.
The Committee understands that VA's authorization to only
pay for the time the resident is training at VA limits VA's
ability to create additional GME positions. In providing this
additional authority, the intent is to provide more residents
with the opportunity to train at VA, and in return, provide
them with the opportunity for full-time employment at VA. The
Committee recognizes that there are challenges to recruitment
and retention, including in rural facilities, and understands
that additional resources and incentives for training and
hiring physicians may be beneficial for VA.
Sec. 212. Pilot program to establish or affiliate with graduate medical
residency programs at facilities operated by Indian tribes,
tribal organizations, and the Indian Health Service in rural
areas.
Section 212 of the Committee bill, a freestanding provision
which is derived from S. 1449, would require VA to establish a
pilot program to establish or affiliate with GME programs at
specified non-VA facilities.
Background. VA is only authorized to fund GME programs
within VA facilities; however, both native and non-native
veterans in some states, such as Alaska, Montana, and Hawaii,
rely heavily on health care provided through facilities
operated by Indian tribes, tribal organizations, or IHS. These
entities provide care to veterans through a memorandum of
understanding, national reimbursement agreement, and agreements
entered into under sections 102 and 103 of P.L. 113-146. Due to
the rural nature of many of these facilities, recruitment of
health care providers can be difficult.
Committee Bill. Within the 1,500 new GME positions required
by Section 211, section 212(a)-(d) would require VA, in
consultation with IHS, to carry out an 8-year pilot program to
establish or affiliate with GME residency training programs at
five facilities operated by an Indian tribe, a tribal
organization, or the IHS that is located in a rural or remote
area. Section 212(e) would require VA to reimburse
participating facilities for specified expenses associated with
the pilot program. Section 212(f) would require residents
participating in the program to fulfill a period of obligated
service and would be eligible for student loan repayment
through VA and IHS. Any period of obligated service required
would be served concurrently with any required service under
the loan repayment programs. Section 212(g) would require that
participants in the pilot program be considered a position
referred to in section 211(a)(1) for purposes of the limitation
on the number of authorized new positions. Section 211(h) would
require VA to submit to Congress a report on the feasibility
and advisability of expanding the pilot program and making it
permanent, 3 years before the termination of the program.
This pilot program is intended to assist with recruiting
health care providers in areas that face recruitment challenges
and strengthen VA partnerships with other facilities that serve
a large number of veterans. It will also provide additional
opportunities for residents to gain specific rural health
experience.
Sec. 213. Reimbursement of continuing professional education
requirements for board certified advanced practice registered
nurses.
Section 213 of the Committee bill, an original provision,
would amend section 7411 of title 38, U.S.C., to require VA to
reimburse continuing professional education expenses for APRNs.
Background. Section 7411 of title 38, U.S.C., requires VA
to reimburse full-time, board-certified physicians or dentists
appointed under section 7401(1) of title 38, U.S.C., for
continuing professional education up to $1,000 per year. This
does not include APRNs. VA has indicated that it agrees with
recommendations from the National Institute of Health and other
health care organizations on the value of continuing education
for APRNs and its important role in the provision of high-
quality care.
Committee Bill. Section 213 would amend section 7421 of
title 38, U.S.C., to require VA to reimburse APRNs for up to
$1,000 per year for continuing medical education expenses.
Sec. 214. Increase in maximum amount of debt that may be reduced under
Education Debt Reduction Program of Department of Veterans
Affairs.
Section 214 of the Committee bill, an original provision,
would increase the maximum amount of loan repayment that can be
provided to medical professionals under VA's EDRP.
Background. Section 7683 of title 38, U.S.C., provides VA
with the authority to carry out EDRP, which provides
educational assistance to VHA employees. EDRP has enabled VHA
to incentivize employees to work for VA or remain with VA by
assisting in the payment of educational debt.
With passage of P.L. 113-146, Congress raised the maximum
amount of loan repayment under EDRP from $60,000 to $120,000
over a 5-year period with not more than $24,000 being paid in
any 1 year of participation of the Program. Despite this
effort, VHA still faces challenges in incentivizing employees
to remain with the Agency because private-sector loan repayment
programs are more generous.
Committee Bill. Section 214(a) of the Committee bill would
increase the maximum amount of loan repayment from $120,000 to
$240,000, and increase the maximum yearly payment under EDRP
from $24,000 to $48,000. The Committee believes maximum use of
this authority will assist VA in attracting high-quality
providers.
Section 214(b) would require a study, within 1 year of
enactment, on the demand for educational debt reduction, to be
submitted to the Senate and House Committees on Veterans'
Affairs. Included in the study would be the requirement that VA
consider vacancies within VHA that are EDRP-eligible, the types
of medical professionals in demand in the nation and VA
projections on the number and type of medical professions that
meet veteran demand.
Sec. 215. Demonstration program on training and employment of
alternative dental health care providers for dental health care
services for veterans in rural and other underserved
communities.
Section 215 of the Committee bill, a freestanding original
provision, would authorize the Secretary to carry out a
demonstration program to establish programs to train and employ
alternative dental health care providers.
Background. Coupled with the shortage of dental
professionals at VA, veterans who reside in rural areas face
increased barriers to accessing dental services. According to
the VHA Office of Rural Health's May 2017's ``Lessons Learned:
A Rural Case Study, Challenges Increasing Access to Dental Care
Among Rural Veterans'':
For individuals living in rural communities, including
Veterans, oral health is a significant public health
issue due to the documented disparities associated with
access and use of dental services. More specifically,
rural Veterans face numerous barriers accessing dental
services, including lack of transportation,
affordability, and limited access to dental providers.
These individuals are more likely to report an unmet
dental need and only access dental services in response
to discomfort or pain. The limited availability of
dental services also contributes to oral health
disparities by reducing access to dental care.
The Centers for Disease Control and Prevention reports that
nearly 70 percent of Americans over the age of 65 have been
diagnosed with a form of periodontal disease. While some
conditions include inflammation of the gums, others are more
serious and result in damage to the soft tissue and/or bone.
Poor oral health can negatively affect a veteran's emotional
well-being as well as his or her ability to speak or eat.
Committee Bill. In order to address the barriers to rural
veterans accessing dental services, Section 215(a) would
authorize the Secretary to carry out a demonstration program to
establish programs to train and employ alternative dental
health care providers to increase access to dental health care
services for veterans who are entitled to VA dental health care
services and reside in rural and other underserved areas.
Section 215(b) would prioritize demonstration sites in
States that do not have a VA facility that offers on-site
dental services. Section 215(c) would authorize dental services
via telehealth when appropriate and feasible. Section 215(d)
would authorize the appropriation of such sums as are necessary
to carry out the demonstration program.
Section 215(e) would define ``alternative dental health
care providers'' the same as the term is defined in section
340G-1(a)(2) of the Public Health Service Act (section 256g-
1(a)(2) of title 42, U.S.C.). Section 340G-1(a)(2) defines
``alternative dental health care providers'' as community
dental health coordinators, advance practice dental hygienists,
independent dental hygienists, supervised dental hygienists,
primary care physicians, dental therapists and dental health
aides.
PART III--OTHER PERSONNEL MATTERS
Sec. 221. Exception on limitation on awards and bonuses for
recruitment, relocation, and retention.
Section 221 of the Committee bill, which is derived from
S. 1325, would amend section 705(a) of P.L. 113--146 to remove
recruitment, relocation, or retention incentives from the
calculation of the annual aggregate of awards and bonuses
payable by the Secretary.
Background. Section 705(a) of P.L. 113--146 limited the
Secretary to an annual aggregate of $360,000,000 for the
payment of awards and bonuses. Section 951(a) of P.L. 114-198
amended section 705(a) of P.L. 113-146 to limit the Secretary
to an annual aggregate of $230,000,000 for FYs 2017 through
2018, $225,000,000 for FYs 2019 through 2021, and $360,000,000
for FYs 2022 through 2024 for the payment of awards and
bonuses.
Committee Bill. Section 221 would amend section 705(a) of
P.L. 113--146 to remove recruitment, relocation, or retention
incentives from the calculation of the annual aggregate of
awards and bonuses payable by the Secretary.
The Committee believes that these particular incentives are
valuable tools for VA's employee recruitment and retention
needs and their use should not be hampered by being aggregated
with other employee awards and bonuses.
Sec. 222. Annual report on performance awards and bonuses awarded to
certain high-level employees of the Department.
Section 222 of the Committee bill, which is derived from
S. 114, would amend chapter 7 of title 38, U.S.C., by adding a
new section 726 to require the Secretary to submit an annual
report on the performance awards and bonuses presented to
regional office directors, directors of VAMCs, and directors of
VISNs.
Background. As VA has come under scrutiny in recent years,
Congress has brought greater accountability to the agency and
focused more on the performance awards and bonuses for Senior
Executive Service employees at the VA. Furthermore, Members of
Congress have in-depth insights about how their local VA
facilities are performing through accounts from their
constituents and interactions with local VA leadership. The
Committee believes that Members advocating for their
constituents and veterans, as well as the American public, are
owed a level of transparency on bonuses that are funded by
taxpayer dollars. Therefore, this section would require an
annual report on bonuses of local VA officials so Members and
the public can ensure bonuses are awarded to top performers.
Committee Bill. Section 222(a) would amend chapter 7 of
title 38, U.S.C., by adding a new section 726 to require the
Secretary to submit an annual report on the performance awards
and bonuses presented to regional office directors, directors
of VAMCs, and directors of VISNs. Each report shall include the
amount of each award or bonus, the job title of each recipient,
and the location where each recipient individual works. Section
222(b) would provide for a clerical amendment to insert new
section 726 in the table of sections at the beginning of
chapter 7.
Sec. 223. Authority to regulate additional pay for certain health care
employees of the Department.
Section 223 of the Committee bill, an original provision,
would amend section 7454 of title 38, U.S.C., by expanding the
definition of compensation to include pay earned by employees
when performing duties authorized by the Secretary or when the
employee is approved to use annual, sick, family medical,
military, or court leave, or other paid absences for which pay
is not already regulated.
Background. This section would allow VA to better regulate
the pay for title 38 hybrid employees and title 5 health care
workers. Hybrid employees are covered by title 38 for
appointment, advancement, and certain pay matters and covered
by title 5 for performance appraisal, leave, hours of duty,
adverse actions, probationary period, reemployment rights,
reduction-in-force, and retirement rules. In 2005, the U.S.
Court of Federal Claims found VA liable in a class action law
suit (Quimby et al. v. U.S.) for weekend pay and night
differential during periods of leave and other paid time off
for two categories of VA employees: registered nurses,
physician assistants, and dental auxiliaries; and title 38
hybrid employees. The court ruled that the Secretary does not
have authority under section 7454 of title 38, U.S.C., or other
statute to regulate the weekend pay and night differential for
hybrid employees during periods of leave and absence, as hybrid
employees receive leave and other benefits under title 5 not
title 38.
In 2012, the court ruled against VA in a companion case
(Adams et al. v. U.S.) in which the plaintiffs alleged that VA
title 5 health care workers who are appointed under section
7408 of title 38 and receive weekend pay under section 7454 of
title 38 were wrongfully deprived of weekend pay during periods
of leave and other paid absence. Again, the contention was that
the Secretary does not have authority under section 7454 of
title 38 to regulate weekend pay for periods of leave and
absence for employees using leave under title 5. This section
would give VA this authority.
Committee Bill. Section 223 would amend section 7454 of
title 38, U.S.C., by expanding the definition of compensation
to include pay earned by employees when performing duties
authorized by the Secretary or when the employee is approved to
use annual, sick, family medical, military, or court leave, or
other paid absences for which pay is not already regulated.
This section would allow the Secretary to issue policy
prohibiting weekend pay and night differential for periods of
leave consistent with government-wide regulations.
Sec. 224. Modification of pay cap for nurses.
Section 224 of the Committee bill, an original provision,
would amend section 7451(c) of title 38, U.S.C., to establish a
higher maximum amount of basic pay for registered nurses up to
level III of the Executive Schedule and for registered nurses
serving as a nurse executive or a grade for the position of
certified nurse anesthetists up to level I of the Executive
Schedule.
Background. According to the OIG FY 2017 VHA occupational
staffing shortages report, the occupational series with the
second largest staffing shortage is nurses. Medical officers
and nurses have been the top two critical need occupations
since the OIG first began the reports in 2014. According to the
FY 2017 VHA nurse staffing report to Congress, the second most
frequently identified reason for nurses leaving is for
advancement (unique opportunity elsewhere). The report
indicates that VHA nurses have an average turnover rate of 9.9
percent and an average vacancy rate of 8.7 percent. Currently,
the maximum rate of basic pay for nurses for any grade may not
exceed the rate of basic pay established for positions at level
IV of the Executive Service.
Committee Bill. Section 224 of the Committee bill would
amend paragraph (2) of section 7451(c) of title 38, U.S.C., to
increase the pay cap for registered nurses. Specifically, the
new paragraph 2 of section 7451(c) would raise the rate of
basic pay for a registered nurse serving as a nurse executive
or a certified registered nurse anesthetist not to exceed level
I of the Executive Schedule under section 5312 of title 5,
U.S.C. The rate of basic pay for all other registered nurses
would be increased not to exceed level III of the Executive
Schedule under section 5314 of title 5, U.S.C.
SUBTITLE B--IMPROVEMENT OF UNDERSERVED FACILITIES OF THE DEPARTMENT
Sec. 231. Development of criteria for designation of certain medical
facilities of the Department of Veterans Affairs as underserved
facilities and plan to address problem of underserved
facilities.
Section 231 of the Committee bill, a freestanding original
provision, would require the Secretary to consider a number of
facility characteristics in developing criteria to designate
those facilities as underserved, with VISN directors using the
criteria to determine annually which facilities in their
networks meet the designation. It would also require the
Secretary to submit an annual plan to Congress for addressing
the problem of underserved facilities.
Background. In accordance with P.L. 113-146, veterans are
eligible to receive care within their community if their local
VA facility cannot schedule an appointment within 30 days of
the clinically indicated date. While this is one metric VHA
uses to assess clinical capacity within individual VHA
facilities, it does not comprehensively measure the extent to
which those facilities are medically underserved. HHS' Health
Resources and Services Administration uses geographic,
population, and facility-based criteria to designate Health
Professional Shortage Areas, which indicate provider shortages
in primary care, dental health, or mental health.
Section 231(a) would require the Secretary to develop
criteria within 180 days to designate VAMCs, ambulatory care
facilities, and community based outpatient clinics as
underserved facilities.
Section 231(b) lists the considerations the Secretary would
need to take when developing criteria for designating
facilities as underserved. Considerations include the ratio of
veterans to health care providers in a geographic area; the
range of clinical specialties covered; whether the local
community is medically underserved; the type, number, and age
of open consults; and whether the facility is meeting VA wait-
time goals.
Section 231(c) would require VISN directors to annually
perform an analysis to determine which facilities within the
VISN qualify as underserved pursuant to the criteria developed
under subsection (a).
Section 231(d) would require the Secretary to submit a plan
to Congress addressing the problem of underserved facilities.
The plan would be required to address a number of topics,
including increasing personnel or temporary personnel
assistance; providing special hiring incentives, using direct
hiring authority; and improving training opportunities.
Committee Bill. In order to address a range of problems
across VHA programs, it is critical for VISN and facility
leadership to be aware of facilities that are in need of
resources. The Committee expects VHA leaders to use the data
required by this provision to better target resources to where
the needs exist.
Sec. 232. Pilot program on tuition reimbursement and loan repayment for
health care providers of the Department of Veterans Affairs at
underserved facilities.
Section 232 of the Committee bill, a freestanding original
provision, would require the Secretary to create a pilot
program to provide tuition reimbursement and loan repayment to
medical students and health care providers in exchange for
their commitment to working in underserved VHA facilities.
Committee Bill. In order to address a range of problems
across VHA programs, it is critical for VISN and facility
leadership to be aware of facilities that are in need of
resources. The Committee expects VHA leaders to use the data
required by this provision to better target resources to where
the needs exist.
Background. VHA facilities with staff vacancies face
challenges in providing timely health care to the veterans they
serve. In addition, approximately 25 percent of all U.S.
veterans reside in rural communities, where basic and
preventative health care may not be available. In particular,
these communities have fewer physicians, hospitals, and other
health care delivery resources. The National Health Services
Corps operates two programs--a scholarship program and a loan
repayment program--to provide financial incentives to certain
students and health care practitioners in exchange for
commitment to work in underserved communities. While VA's EDRP
aims to fill clinical positions that are difficult to recruit
or retain by offering student loan reduction payments, it does
not have a particular focus on addressing the recruitment and
retention challenges that rural facilities face.
Committee Bill. Section 232(a) would require the Secretary
to commence a pilot program to assess the feasibility and
advisability of providing tuition reimbursement and loan
repayment to medical students and health care providers who
commit to serving in underserved facilities within 90 days of
enactment.
Section 232(b) would set the duration of the pilot program
at 6 years from the date of commencement.
Section 232(c) would require the Secretary to select no
fewer than three VAMCs and seven ambulatory care facilities or
community based outpatient clinics located in at least eight
different states to participate in the pilot program. No fewer
than two of the VAMCs and five of the ambulatory care
facilities or community based outpatient clinics would be
located in states or United States territories that are among
the ten states or territories with the highest percentage of
land designated as highly rural by the Department of
Agriculture or the highest percentage of enrolled veterans
living in rural, highly rural, or insular island areas.
Participating facilities would be required to be located in not
fewer than eight states.
Section 232(d) would designate half of the amount spent on
the program to be for tuition reimbursement or loan repayment
for individuals practicing in a general practice position. The
other half would be for individuals practicing in a specialist
position or in an occupation included in the most recent
staffing shortage determination by the VA OIG.
Section 232(e) would authorize the Secretary to provide an
individual attending medical school with full tuition
reimbursement in exchange for a 5-year commitment to serve at
an underserved facility.
Section 232(f) would authorize the Secretary to provide
individuals who commit to serving 3 years at an underserved
facility with up to $50,000 student loan repayment. Current VHA
health care providers at underserved facilities may receive up
to $30,000 student loan repayment. The Committee intends that
this increased loan repayment authority be used to incentivize
providers to work in underserved facilities at VA.
Section 232(g) describes the procedure for the United
States to recoup amounts provided to pilot participants who
fail to satisfy the period of obligated service and would
require that any individual who fails to fulfill the required
period of obligated service be liable to the United States for
any amount that has been paid on the individual's behalf,
reduced by the proportion that the number of days served for
completion of the period of obligated service bears to the
total number of days in the period of obligated service of such
individual.
Section 232(h) would require the Secretary to ensure that
hiring done under the pilot program is expedited.
Section 232(i) would ensure continued program participation
by pilot participants selected because they work in occupations
included in the VA OIG staffing shortage determination, in
cases where their occupations are no longer included in the
determination.
Section 232(j) would require the Secretary to submit to
Congress annually a report on the pilot program. The report
would be required to include the number of participants, the
number of facilities where participants are located, the number
of program applicants, and the five most common occupations of
participants, other than general practice. The Committee
expects that if the Secretary believes modifications should be
made to improve the pilot program, that the Secretary recommend
such changes in the annual report, if not sooner.
Section 232(k) defines the terms ``enrolled veteran'' and
``underserved facility.''
Staff vacancies in rural and medically underserved areas
continue to be a challenge VHA has not been able to address
sufficiently. The Committee expects VHA to make a concerted
effort to carry out the pilot program required in Section 232
with open-mindedness about if and how such a program could be
expanded nationwide.
Sec. 233. Program to furnish mobile deployment teams to underserved
facilities.
Section 233 of the Committee, a freestanding original
provision, bill would establish a program to provide mobile
deployment teams of medical personnel to underserved
facilities.
Background. P.L. 113-146 was enacted in response to widely-
reported scheduling irregularities at VA. That legislation
sought to relieve strain on the VA health care system by
allowing some veterans to opt-in to community care. It also
sought to bolster VA's internal capacity to provide care by
providing increased funding for the hiring of medical
professionals and authorizing clinic leases so that veterans
could get care closer to home. Finally, it gave the Secretary
improved tools for removing poor-performing employees.
Subsequent legislation, such as the Accountability Act, further
provided the Secretary with the tools necessary to hold
employees accountable. While VA has made great progress in
remediating problem areas in health care delivery and improving
local facility management, challenges remain.
Committee Bill. The Committee believes that mobile
deployment teams, made up of a diversified group of personnel
to address urgent and emergent challenges in VHA, would assist
VA in addressing problem-areas quickly and succinctly. These
teams could investigate, solve, recommend and carry-out actions
to address problems at VA medical facilities.
Section 233(a) would establish a program to furnish mobile
deployment teams of medical personnel to underserved
facilities. It is the Committee's intent that these mobile
deployment teams assist VA facilities with urgent and emergent
challenges that prevent or will prevent the furnishing of high-
quality and timely health care to veterans. For example, if a
local facility is experiencing challenges scheduling consults,
the Committee believes that a multi-disciplinary team
dispatched to address consult challenges would help mitigate
scheduling problems before patient care is affected. In this
instance, team members might include: information technology
personnel, training personnel, scheduling personnel, quality
personnel, human resources personnel, and public affairs
personnel to address veterans' concerns. It is the Committee's
intent that the use of a mobile deployment team not be
considered punitive, but rather a tool to supplement existing
VA resources at any given facility. The Committee also believes
that better communication between the Central Office of the
Department, VISN and local facilities would assist in
mitigating problems before they become a crisis.
Section 233(b) would establish elements that the Secretary
must consider when determining whether to furnish mobile
deployment teams, including: the medical positions of greatest
need at underserved facilities; the size and composition of
teams to be deployed; and any other elements the Secretary
considers necessary for effective oversight of the mobile
deployment program.
Section 233(c) would require the annual analysis conducted
under section 231(c) of the Committee bill to form mobile
deployment teams that are composed of the most needed medical
personnel for underserved facilities.
Section 233(d) would define ``underserved facility'' that
meets the criteria established under Section 231 of the
Committee bill.
Sec. 234. Inclusion of Vet Center employees in education debt reduction
program of Department of Veterans Affairs.
Section 234 of the Committee bill, a freestanding original
provision, would direct the Secretary to ensure clinical staff
working at Vet Centers are eligible to participate in EDRP
under chapter 76 of title 38, U.S.C.
Background. Section 7682, title 38, U.S.C. establishes
eligibility for EDRP. Employees must be serving in a direct-
patient care service or a service incident to a direct-patient
care position for which retention or recruitment is difficult
and the principal or interest balance on their loan must be for
paying the costs related to a course of education or training
related to that position.
Committee Bill. Section 234(a) of the Committee bill would
direct the Secretary to ensure that Vet Center employees are
eligible for EDRP. Section 234(b) also directs the Secretary to
submit a report to Congress on the number of participants in
the program, who work at Vet Centers, no later than 1 year
after the enactment of the bill. Section 234(c) would define
the term ``Vet Center'' as having the same meaning of the term
in section 1712A(h) of title 38, U.S.C. Vet Centers address a
critical clinical need for veterans with a high risk for mental
health issues. Therefore, the Committee believes this provision
reflects that the same recruitment and retention tools should
be made available and a priority for clinical staff at these
facilities.
SUBTITLE C--CONSTRUCTION AND LEASES
Sec. 241. Definition of major medical facility project and major
medical facility lease.
Section 241 of the Committee bill, an original provision,
would amend section 8101 of title 38, U.S.C., to redefine the
term ``medical facility'' and would amend section 8104 of title
38, U.S.C., to redefine the terms ``major medical facility
project'' and ``major medical facility lease.''
Background. Section 8101(3) of title 38, U.S.C., defines
``medical facility'' as ``any facility or part thereof which
is, or will be, under the jurisdiction of the Secretary for the
provision of health-care services (including hospital, nursing
home, or domiciliary care or medical services), including any
necessary building and auxiliary structure, garage, parking
facility, mechanical equipment, trackage facilities leading
thereto, abutting sidewalks, accommodations for attending
personnel, and recreation facilities associated therewith.''
Section 8101(3) has never been amended.
Section 8104(a)(3)(A) of title 38, U.S.C., defines ``major
medical facility project'' as ``a project for the construction,
alteration, or acquisition of a medical facility involving a
total expenditure of more than $10,000,000.'' Section
8104(a)(3)(A) was last amended in P.L. 109-461, the Veterans
Benefits, Health Care, and Information Technology Act of 2006,
when the limit was increased from $7 million to $10 million.
Section 8104(a)(3)(B) of title 38, U.S.C., currently
defines a ``major medical facility lease'' as a lease for space
at an average annual rent of more than $1 million. Section
8104(a)(3)(B) was last amended in P.L. 110-387, the Veterans'
Mental Health and Other Care Improvements Act of 2008, when the
annual rent amount was increased from $600,000 to $1 million.
Committee Bill. Section 241(a) would amend section 8101(3)
of title 38, U.S.C., to expand the term ``medical facility'' to
include any facility or part thereof which is, or will be,
under the jurisdiction of the Secretary, or as otherwise
authorized by law, for the provision of health care services
and includes an outpatient clinic under the definition.
Section 241(b) would amend section 8104(a)(3)(A) of title
38, U.S.C., to increase the limit above which a project is
considered a major medical facility project requiring
Congressional authorization from $10 million to $20 million.
The definition would exclude an acquisition by exchange, non-
recurring maintenance projects, or a shared Federal medical
facility for which VA's estimated share does not exceed $20
million.
Section 241(c) would amend section 8104(a)(3)(B) of title
38, U.S.C., to define the term ``major medical facility lease''
to align with the rental value used by the General Services
Administration under section 3307(a)(2) of title 40, U.S.C.,
and is subject to annual adjustment in accordance with section
3307(h) of title 40, U.S.C. The FY 2017 General Services
Administration annual prospectus threshold is $2,850,000,000.
Sec. 242. Facilitating sharing of medical facilities with other Federal
agencies.
Section 242 of the Committee bill, an original provision,
would create a new section 8111B of title 38, U.S.C., to
authorize the Secretary to enter into agreements with other
Federal agencies for planning, designing, constructing, or
leasing shared medical facilities. It would authorize the
Secretary to transfer to another Federal agency amounts
appropriated for minor construction projects, major
construction projects, and leased projects. Funds transferred
to VA from other Federal agencies could be used for planning,
designing, or constructing a shared medical facility for minor
construction projects, major construction projects, and leased
projects.
Background. Established by section 583 of P.L. 108-136,
National Defense Authorization Act for Fiscal Year 2004, the
VA/DOD Joint Executive Committee (hereinafter, ``JEC'')
recommends to the Secretaries of the Departments a strategic
direction for the joint coordination and sharing efforts
between and within the two Departments. The VA/DOD Construction
Planning Committee established under the JEC provides a
formalized structure to facilitate cooperation and
collaboration for shared medical facilities that are mutually
beneficial to both Departments. Even with this collaborative
structure in place, VA and DOD continue to encounter challenges
when attempting to plan and construct joint medical facility
projects. Differing definitions and thresholds for construction
project accounts and differing authorization and appropriations
requirements for each Department create significant barriers to
planning future joint medical facility projects.
Committee Bill. Section 242(a) would amend subchapter I of
chapter 81 of title 38, U.S.C., by creating a new section
8111B. Section 8111B(a) authorizes the Secretary to enter into
agreements with other Federal agencies for planning, designing,
constructing, or leasing shared medical facilities with the
goal of improving access to, and quality and cost effectiveness
of, health care provided by VA and other Federal agencies.
These facilities will be managed by the Under Secretary for
Health.
Section 8111B(b) would authorize the Secretary to transfer
to another Federal agency amounts appropriated for minor
construction projects, major construction projects, and leased
projects.
Section 8111B(c) would allow funds transferred to VA from
other Federal agencies to be used for planning, designing, or
constructing a shared medical facility for minor construction
projects, major construction projects, and leased projects.
Amounts transferred into VA will be available for the same time
period as amounts in the account to which those amounts are
transferred.
Section 242(b) would provide a clerical amendment to the
table of sections at the beginning of chapter 81 of title 38,
U.S.C.
The Committee understands the challenges inherent in joint
medical facility projects and anticipates this new authority
would lead to an increase in collaboration between DOD and VA
on eligible physical infrastructure projects.
Sec. 243. Review of enhanced-use leases.
Section 243 of the Committee bill, an original provision,
would amend section 8162(b)(6) of title 38, U.S.C., to require
the Office of Management and Budget (hereinafter, ``OMB'') to
review each enhanced-use lease before the lease goes into
effect to determine whether the lease is in compliance with
section 8162(b)(5) of title 38, U.S.C.
Background. Under section 8162(b)(6) of title 38, U.S.C.,
the Secretary is prohibited from entering into an enhanced-use
lease without certification in advance in writing by the
Director of OMB that such lease complies with the requirements
of section 8162.
Committee Bill. Section 243 would modify the OMB's role in
enhanced-use leases executed by VA. OMB would review whether
the lease is in compliance with enhanced-use lease regulations,
not grant approval. The Committee expects this change will
reduce the administrative burden of the previous certification
requirement and decrease the time required to complete the OMB
process.
Sec. 244. Authorization of certain major medical facility projects of
the Department of Veterans Affairs.
Section 244 of the Committee bill, a freestanding original
provision, would authorize not more than $117,300,000 for
Phases III and V of the realignment of facilities in Livermore,
California, and would require a detailed project proposal and
accounting of current and future expenditures for the project.
Background. In its FY 2018 budget submission, VA requested
$117,300,000 for the construction of Phases III and V of the
realignment and closure project in Livermore, California. Phase
III is the construction of a new East Bay Community Based
Outpatient Clinic in Fremont, California. The facility will be
approximately 80,000 gross square feet and will include site
enhancements such as parking, utilities, flood plain
mitigation, and landscaping as appropriate. Phase V is the
construction of an approximately 20,000 gross square feet
Central Valley Engineering and Logistics Support Facility,
which will be collocated with the Phase I community living
center and Phase II Community Based Outpatient Clinic, and will
include site enhancements such as parking, utilities, flood
plain mitigation, and landscaping as appropriate. The overall
project has been appropriated $55,430,000 in fiscal year 2010
for design funds and $139,000,000 in FY 2016 for the Phase II
Community Based Outpatient Clinic in New Central Valley,
California.
Committee Bill. Section 244(a) would authorize the
construction of the new East Bay Community Based Outpatient
Clinic and all associated site work, utilities, parking, and
landscaping, construction of the Central Valley Engineering and
Logistics support facility, and enhanced flood plain mitigation
at the Central Valley and East Bay Community Based Outpatient
Clinics as part of the realignment of medical facilities in
Livermore, California, in an amount not to exceed $117,300,000.
Section 244(b) would authorize the appropriation of
$117,300,000 for FY 2018 or the year in which funds are
appropriated for the Construction, Major Projects account, for
the project authorized in section 244(a).
Section 244(c) would require the Secretary to submit to the
House and Senate Committees on Veterans' Affairs within 90 days
a detailed project proposal, line item accounting of
expenditures, any future obligations for the project, a
justification for the expenditures, and any agreements with a
non-VA Federal entity to provide construction services for the
project.
SUBTITLE D--OTHER HEALTH CARE MATTERS
Sec. 251. Program on use of wellness programs as complementary approach
to mental health care for veterans and family members of
veterans.
Section 251 of the Committee bill would, a freestanding
original provision, provides VA with authority to provide
grants to public and private nonprofit entities for the purpose
of determining whether wellness programs will improve veterans'
well-being and quality of life.
Background. This section would require VA to carry out a
program to assess the feasibility and advisability of using
wellness programs to complement the provision of mental health
care to certain veterans and family members of veterans. The
section operationalizes this by creating a grant fund for
public and private nonprofit entities to study the benefits of
complementary wellness programs to better care for veterans and
improve their well-being and quality of life. Veterans eligible
to participate are those eligible for counseling under section
1712A(a)(1)(c) of title 38, U.S.C. Under current law, VA's
Readjustment Counseling Service does not have the ability to
provide grants to public or private non-profit entities.
Committee Bill. Section 251(a)(1) would provide authority
to carry out a program to assess the feasibility and
advisability of using wellness programs to complement the
provision of mental health care to certain veterans and family
members of veterans. Veterans eligible to participate are those
eligible for counseling under section 1712A(a)(1)(c) of title
38, U.S.C.
Section 251(a)(2) bill would establish the matters that the
program will assess. Specifically, the program would look at
coordination between governmental and community providers in
delivering mental health care to eligible veterans and family
members; enhancing outreach and coordination of outreach by
providers to eligible veterans and family members; use of
wellness programs by providers complementary to mental health
care from VA; whether such wellness programs are effective in
enhancing the quality of life and well-being of veterans and
family members; whether the wellness programs increase the
adherence of eligible veterans to the primary mental health
services they receive from VA; whether the wellness programs
have an impact on the veterans' sense of well-being; and
whether the wellness programs are effective in encouraging the
veterans to adopt a more healthy lifestyle.
Section 251(b) would establish that the Secretary shall
carry out the program for 3 years beginning 1 year after the
Committee bill is enacted. Section 251(c) would establish that
the Secretary shall carry out the program at VA facilities
providing mental health care to eligible veterans and family
members.
Section 251(d)(1) would establish that public or private
nonprofit entities seeking grant awards shall do so by
submitting an application to the Secretary as the Secretary
sees fit.
Section 251(d)(2) would describe what the grant proposal
applications must contain.
Section 251(d)(2)(A) would describe the plan to coordinate
activities under the program between providers of services to
veterans to enhance veteran care. Specifically, the plan would
provide awareness of VA's benefits and health care services;
outreach efforts to increase veterans' use of VA services; and
educational efforts to inform veterans of the benefits of
healthy and active lifestyle.
Section 251(d)(2)(B) would require a statement of
understanding that the entity will be required to report to the
Secretary on data and performance measures necessary to
evaluate individual outcomes and facilitate evaluations among
entities participating. Section 251(d)(2)(C) would enable the
Secretary to collect other information as required. Section
251(e)(1) would require the entity awarded a grant to use the
award for the purposes prescribed by the Secretary. Section
251(e)(2) would require the entity awarded a grant to use the
award only to furnish services to the individuals specified in
section 1712A(a)(1)(c) of title 38, U.S.C. for such purposes as
described in section 251(e)(1).
Section 251(f) would require VA, not later than 180 days
after the commencement of the program and every 180 days
thereafter, to submit to Congress a report on the Secretary's
findings and conclusions on the program for the 180 preceding
days and an assessment of the benefits of the program for
veterans and their family members during the 180 preceding
days. Further, not later than 180 days after the end of the
program, the Secretary shall submit to Congress a report
detailing the Secretary's recommendations as to the
advisability of continuing or expanding the program.
Section 251(g) defines the term ``wellness'' as having the
meaning as described by the Secretary in such regulations as
the Secretary will promulgate.
Sec. 252. Authorization to provide for operations on live donors for
purposes of conducting transplant procedures for veterans.
Section 252 of the Committee bill, which is derived from
S. 115, would add a new section to Chapter 17 of title 38,
U.S.C., to allow VA to provide transplant procedures with live
donors at VA facilities or non-VA facilities regardless of
whether the live donor is a veteran.
Background. VA has been providing solid organ transplant
procedures on veterans since 1962 and bone marrow transplant
procedures since 1982. While transplant care and treatment is
provided at 1,065 outpatient clinics and 170 VAMCs, 13 VAMCs
are designated VA Transplant Centers. In limited circumstances,
VA will provide treatment to non-veterans for emergency
conditions or some VA facilities may treat dependents covered
under the CHAMPVA Program. Under current law, VA cannot perform
a transplant procedure on a live donor that is not a veteran
because that person is not eligible for care or treatment at
VA.
Committee Bill. Section 252 would allow VA to provide
transplant procedures with live donors at VA facilities or in
the community. Specifically, section 252(a) would add a new
section to chapter 17 of title 38, U.S.C., section 1788.
Section 1788(a) would allow VA to provide transplant procedures
to a veteran with a live donor if the donor is not a veteran or
not otherwise eligible for health care in VA. Section 1788(b)
would direct VA to provide the care and services to the donor
required in connection with the transplant procedure. Section
1788(c) would allow VA to provide the transplant procedures
through a VA community care program and would deem the donor an
individual eligible for VA's community care program for the
purposes of the transplant procedure. Section 252(b) would make
a clerical change to add section 1788 to the table of contents
for chapter 17 of title 38, U.S.C.
Sec. 253. Sense of the Senate.
Section 253, a freestanding original provision, would
express the Senate's concern to preserve VHA's network of care,
ensure it is effectively resourced, and oppose any efforts to
privatize the system.
Committee Bill. Section 253 would express the Senate's
concern to preserve VHA's network of care, ensure it is
effectively resourced, and oppose any efforts to privatize the
system.
TITLE III--FAMILY CAREGIVERS
Sec. 301. Expansion of family caregiver program of Department of
Veterans Affairs
Subsec. 301(a)(1). Expansion of family caregiver program of
Department of Veterans Affairs.
Section 301(a)(1) of the Committee bill, which is derived
from S. 591, would expand eligibility for VA's Program of
Comprehensive Assistance for Family Caregivers.
Background. The Caregivers and Veterans Omnibus Health
Services Act of 2010 was signed into law on May 5, 2010. It
established the Program of General Caregiver Support Services
and the Program of Comprehensive Assistance for Family
Caregivers. The Program of Comprehensive Assistance for Family
Caregivers (hereinafter, ``the Program'') provides additional
support services to caregivers beyond what is provided through
the Program of General Caregiver Support Services, including a
monthly financial stipend, health care coverage through
CHAMPVA, counseling and mental health services, respite care,
and technical assistance. The Program is only available to
veterans who have serious injuries (including traumatic brain
injury, psychological trauma, or other mental disorder)
incurred or aggravated in the line of duty in the active
military, naval, or air service on or after September 11, 2001.
In September 2014, GAO released a report on the Program
titled ``Actions Needed to Address Higher-Than-Expected Demand
for the Family Caregiver Program.'' The report noted,
``Caregivers enable those for whom they are caring to live
better quality lives and can contribute to faster
rehabilitation and recovery.'' Supporting caregiving activities
not only ensures equity of services and benefits available to
the caregivers of our most seriously injured veterans, it may
further enable veterans to remain at home rather than admitting
them to a potentially more expensive institutional setting,
such as a nursing home.
Prior to the Program's implementation, VA initially
estimated that 4,000 caregivers would be approved for the
program; however, as of November 2, 2017, 21,990 caregivers had
been approved. GAO's 2014 report on the Program made specific
recommendations for improvement. Among its recommendations, GAO
recommended that VA ``expedite the process for identifying and
implementing an [IT] system that fully supports the program and
will enable [VHA] program officials to comprehensively monitor
the program's workload, including data on the status of
applications, appeals, home visits, and the use of other
support services, such as respite care.'' GAO also recommended
that the VA Secretary direct the Under Secretary for Health
``to use data from the IT system, once implemented, as well as
other relevant data to formally reassess how key aspects of the
program are structured and to identify and implement
modifications as needed to ensure that the program is
functioning as envisioned so that caregivers can receive the
services they need in a timely manner.''
Committee Bill. Section 301(a)(1) would amend section 1720G
of title 38, U.S.C., to require VA to expand eligibility for
the Program to all eras of veterans in two phases. The first
phase of expanded eligibility would begin during the 2-year
period beginning on the date on which the VA Secretary submits
to Congress a certification that VA has fully implemented an IT
system to support the Program. Section 301(a)(1)(B) of the
Committee bill would require VA to submit the certification
date in the Federal Register within 30 days to ensure public
notification. The first phase includes veterans with a serious
injury incurred or aggravated in the line of duty in the active
military, naval, or air service on or before May 7, 1975. The
second phase of eligibility would begin 2 years after the first
phase. This includes those injured in the line of duty after
May 7, 1975, and before September 11, 2001.
The current eligibility criteria creates an inequity
between post-9/11 veterans and pre-9/11 veterans. However, VA
has encountered numerous challenges in implementing the
program, and it is clear improvements are needed to ensure the
program is meeting the needs of those currently enrolled and
can sustain an increase in eligible veterans. The Committee
bill ensures those improvements are made prior to expansion to
pre-9/11 veterans and their caregivers.
For example, the Program's expansion in two phases, as
required by this section, is intended to ensure the Program
does not get overwhelmed and continues to operate as intended,
providing services in a timely manner, while enrolling those
who have become newly eligible. The publication of the VA
Secretary's certification date in the Federal Register is
intended to ensure veterans are notified of the Program's
impending expansion.
Subsec. 301(a)(2). Expansion of needed services in
eligibility criteria.
Section 301(a)(2) of the Committee bill, which is derived
from S. 591, would expand the Program's eligibility criteria
for needed services.
Background. Current law, section 1720G of title 38, U.S.C.,
provides that veterans eligible for the Program must be in need
of personal care services because of an inability to perform
one or more activities of daily living, a need for supervision
or protection based on symptoms or residuals of neurological or
other impairment or injury, or such other matters as the
Secretary considers appropriate.
Committee Bill. Section 301(a)(2) would amend subsection
(a)(2)(C) of section 1720G of title 38, U.S.C., to include a
need for regular or extensive instruction or supervision
without which the ability of the veteran to function in daily
life would be seriously impaired among the criteria considered
for needed personal care services. It is the intent of the
Committee to ensure the Program is consistently inclusive of
the caregiving needs required by mental health conditions,
traumatic brain injuries or other conditions with which
eligible veterans may be diagnosed.
Subsec. 301(a)(3). Expansion of services provided.
Section 301(a)(3) of the Committee bill, which is derived
from S. 591, would expand the services provided to caregivers
under the Program to include legal and financial planning
services.
Background. In 2014, the RAND Corporation released a
report, ``Hidden Heroes: America's Military Caregivers,'' which
examined characteristics of military caregivers and services
available to them. The report indicates that, of the military
caregiver-specific programs identified by RAND, few provide
long-term planning assistance, including legal and financial
planning, for military caregivers.
Committee Bill. Section 301(a)(3) would amend subsection
(a)(3)(A)(ii) of section 1720G of title 38, U.S.C., to require
VA to include financial planning services and legal services
related to the needs of injured veterans and their caregivers
as among the services provided to caregivers. The section makes
clear that VA should provide these services through the use of
contracts with or the provision of grants to public or private
entities.
While section 301(a)(3) would require that financial
planning and legal services be offered to caregivers in the
Program, it is the Committee's intent that VA and VA employees
not provide these services, but instead partner with public or
private entities. It is also the Committee's intent that, to
the maximum extent practicable, VA should utilize partnerships
that will provide the services pro bono.
Subsec. 301(a)(4). Modification of stipend calculation.
Section 301(a)(4) of the Committee bill, which is derived
from S. 591, would expand the number of factors VA should
consider when determining the amount and degree of personal
care services provided for certain veterans.
Background. Currently, there are three levels of caregiver
stipends based on the amount and degree of personal care
services provided. This was established pursuant to section
1720G of title 38, U.S.C. According to current regulations, the
stipend payment is based on the number of hours of caregiving
required by the veteran. The maximum stipend is based on the
requirement of 40 hours of caregiving each week, the median
stipend is based on the requirement of 25 hours of caregiving
each week, and the lowest stipend is based on the requirement
of 10 hours of caregiving each week. In order to determine the
degree of personal care services required by the veteran, VA
evaluates the veteran and establishes a clinical rating based
on specific criteria regarding the ability to perform
activities of daily living and the need for supervision or
protection based on symptoms or residuals of neurological or
other impairment or injury.
Committee Bill. Section 301(a)(4) would amend subsection
(a)(3)(C) of section 1720G of title 38, U.S.C., to ensure VA is
considering the assessment by the family caregiver of the needs
and limitations of the veteran; the extent to which the veteran
can function safely and independently in the absence of such
supervision, protection, or instruction; and the amount of time
required for the family caregiver to provide such supervision,
protection, or instruction to the veteran when determining the
amount and degree of personal care services provided for a
veteran whose need for personal care services is based on a
need for supervision or protection or regular instruction or
supervision under subsection (a)(2)(C) of section 1720G of
title 38, U.S.C.
The Committee understands that these determinations are
made at the VAMC level and the intent is to ensure consistency
by VA in determining the amount of hours of caregiving required
by the veteran.
Subsec. 301(a)(5). Periodic evaluation of need for certain
services.
Section 301(a)(5) of the Committee bill, which is derived
from S. 591, would require VA to periodically evaluate the
needs of the veteran and the skills of the family caregiver to
determine if additional instruction, preparation, training, or
technical support is needed.
Background. Under section 1720G of title 38, U.S.C., VA is
required to provide instruction, preparation, and training for
family caregivers to provide care to veterans, in addition to
ongoing technical support to address routine, emergency, and
specialized caregiving needs of the family caregiver.
Committee Bill. Section 301(a)(5) would amend subsection
(a)(3) of section 1720G of title 38, U.S.C., to require that,
in providing instruction, preparation, and training under
subparagraph (A)(i)(I) of that section and technical support
under subparagraph (A)(i)(II) of that section to each approved
family caregiver, the Secretary periodically evaluate the needs
of the veteran and the skills of the family caregiver to
determine if additional instruction, preparation, training, or
technical support is necessary.
The requirement for periodic evaluation of this support
will ensure that caregivers have ongoing access to resources
and support for their unique needs as they care for veterans,
especially given that a veteran's needs and caregiving
techniques and best practices may change over time.
Subsec. 301(a)(6). Use of primary care teams.
Section 301(a)(6) of the Committee bill, which is derived
from S. 591, would require the VA Secretary to collaborate with
the veteran's primary care team when evaluating applications
for the Program, to the extent practicable.
Background. Under subsection (a)(5) of section 1720G of
title 38, U.S.C., when reviewing applications submitted jointly
by the veteran and family caregiver, VA is required to evaluate
the veteran to identify the personal care services required and
to determine whether the requirements could be significantly or
substantially satisfied through personal care services from a
family member. The determination for a veteran's approval for
the Program is a clinical decision; however, there is no
statutory requirement that VA include the veteran's primary
care team in the evaluation.
Committee Bill. Section 301(a)(6) would amend subsection
(a)(5) of section 1720G of title 38, U.S.C., to require that
the Secretary evaluate each application submitted jointly by an
eligible veteran and family member in collaboration with the
veteran's primary care team to the maximum extent practicable.
Though the veteran's primary care team maintains the
veteran's treatment once in the Program, it is the intent of
the Committee to ensure multidisciplinary input in the initial
evaluation process, when possible.
Subsec. 301(a)(7). Assistance for family caregivers.
Section 301(a)(7) of the Committee bill, which is derived
from S. 591, would authorize VA, in providing caregiver
services required under current law, to partner with Federal
agencies, States, and private, non-profit, and other entities
to provide the assistance.
Background. There are numerous public and private entities
that provide caregiver services. According to VA's FY 2016
annual report to Congress on assistance and support services
for caregivers, VA has contracted and collaborated with non-
profit organizations to provide the family caregivers' core
curriculum training and optional additional training
opportunities. VA has also indicated that it works with respite
care providers in communities to provide that service to
veterans in the Program.
Committee Bill. Section 301(a)(7) would amend subsection
(a) of section 1720G of title 38, U.S.C., to authorize VA to
enter into contracts, provider agreements, and memoranda of
understanding with Federal agencies, States, and private, non-
profit, and other entities to provide family caregiver services
required by section 1720G of title 38, U.S.C. The VA Secretary
may provide assistance under this authority only if it is
reasonably accessible to the family caregiver and is
substantially equivalent or better in quality to similar
services provided by VA. In addition, the Secretary could
provide fair compensation to entities that provide assistance
under this authority.
The Committee recognizes that other entities provide
services the Program is required to provide, including respite
care, and that VA in some cases is already partnering with
these other entities to provide services. It is the Committee's
intent that, if appropriate in order to provide the services
and they are equivalent or better in quality to similar
services provided by VA, VA continues to utilize its authority
to partner with entities. This could ensure availability of
services and could reduce any duplication.
Subsec. 301(b). Modification of definition of personal care
services.
Section 301(b) of the Committee bill, which is derived from
S. 591, would modify the definition of personal care services.
Background. Subsection (d)(4) of section 1720G of title 38,
U.S.C., defines ``personal care services'' as services that
provide the veteran assistance with one or more independent
activities of daily living (subsection (d)(4)(A) of section
1720G of title 38, U.S.C.) and any other non-institutional
extended care (subsection (d)(4)(B) of section 1720G of title
38, U.S.C.).
Committee Bill. Section 301(b)(1) would strike
``independent'' in subsection (d)(4)(A) of section 1720G of
title 38, U.S.C., and amend subsection (d)(4) to include
supervision or protection based on symptoms or residuals of
neurological or other impairment or injury and regular or
extensive instruction or supervision without which the ability
of the veteran to function in daily life would be seriously
impaired.
This section is consistent with changes made by sections
301(a)(2) and 301(a)(4) of the Committee bill, which recognize
the need for regular or extensive instruction or supervision
within the definition of personal care services and ensure the
consideration of these personal care needs when determining the
caregiver stipend.
Sec. 302. Implementation of information technology system of Department
of Veterans Affairs to assess and improve the family caregiver
program.
Section 302 of the Committee bill, a freestanding provision
derived from S. 591, would require VA to implement a new IT
system and conduct ongoing monitoring and modifications after
the system is implemented.
Background. The requirement that VA implement a new IT
system that can easily retrieve data that will allow all
aspects of the Program to be assessed and comprehensively
monitored, that can manage data, and that has the ability to
integrate with other relevant VHA IT systems, is consistent
with recommendations made by GAO in its September 2014 report.
The report indicated that the IT system currently utilized, the
Caregiver Application Tracker, was developed quickly due to
time constraints on implementing the Program. VA initially
expected the Program to be much smaller, and the Caregiver
Application Tracker was not designed to manage a high volume of
information. As a result, VA is not able to effectively monitor
and assess the Program.
Committee Bill. Section 302 would outline requirements for
implementing an IT system. Section 302(a) of the Committee bill
would require VA to implement an IT system that fully supports
the Program and allows for data assessment and comprehensive
monitoring of the Program not later than June 1, 2018. The IT
system would also be required to include the ability to easily
retrieve data that will allow for comprehensive monitoring of
all aspects of the Program and workload trends, in addition to
the ability to manage data with respect to a number of
caregivers that is greater than the number of caregivers
expected to apply for the Program, and the ability to integrate
the system with other relevant VHA IT systems. These
requirements are consistent with the GAO recommendations, and
it is the Committee's understanding that the process for
developing the new IT system to support the Program is already
underway.
Section 302(b) of the Committee bill would require VA to
use the IT system to assess key aspects of the Program within
180 days of implementation. Section 302(c) of the Committee
bill would require VA to also use the IT system for ongoing
monitoring and assessment, including data on the status of
applications and the use by caregivers of support services such
as respite care. In addition, VA would be required to identify
and implement necessary modifications to ensure the Program is
functioning as intended and providing veterans and caregivers
with services in a timely manner. These requirements are also
consistent with the recommendations made by GAO. In order for
expansion of the Program to begin, the Secretary must certify
to the Committee on Veterans' Affairs of the Senate and House
of Representatives and the Comptroller General that the IT
system has been implemented. Section 302(d)(3) of the Committee
bill would require VA to submit the certification, along with a
description of its implementation and utilization for program
monitoring not later than June 1, 2019.
Section 302(d)(1) of the Committee bill would require VA,
within 90 days of enactment, to submit a report to the
Committee on Veterans' Affairs of the Senate and House of
Representatives and the Comptroller General, providing an
update on the status of the planning, development, and
deployment of the IT system. The section would also require
that the report include an assessment of the needs of family
caregivers and veterans who would be eligible for the Program,
as expanded, as well as resources needed for their inclusion.
The intent of this requirement is to ensure proper
preparation for the expansion. The Committee expects to be kept
up to date on the progress of the IT system implementation and
deployment and be informed of any changes to the timeline. By
including GAO as a recipient of the report, GAO will have the
opportunity to review VA's progress in implementing its
recommendations, as required by section 302(d)(2) of the
Committee bill. The Committee understands that GAO's audit
quality control processes require GAO to at least annually
follow up on, track, and record the extent to which GAO's
recommendations have been implemented. The Committee expects
GAO to follow up on its recommendations for the Program more
often than annually and to periodically inform the Committees
on VA's implementation status until VA has taken the
appropriate corrective actions to address GAO's findings and
recommendations. The Committee also directs the Comptroller
General to notify the Committee on Veterans' Affairs of the
Senate and the House of Representatives once it has verified
that the recommended actions have been implemented and, to the
extent possible, that the desired outcomes are being achieved,
within 45 days of that determination.
Sec. 303. Modifications to annual evaluation report on caregiver
program of Department of Veterans Affairs.
Section 303 of the Committee bill, which is derived from
S. 591, would amend requirements for VA's annual evaluation
report on VA's caregiver programs.
Background. P.L. 111-163, the Caregivers and Veterans
Omnibus Health Services Act of 2010, requires VA to submit an
annual report to the Committees on Veterans' Affairs of the
Senate and House of Representatives. Currently, VA is required
to report on both the Program of Comprehensive Assistance for
Family Caregivers and the Program of General Caregiver Support
and include information regarding the number of caregivers
receiving assistance, the cost to VA to provide such
assistance, a description of outcomes achieved by the program,
an assessment of their effectiveness and efficiency, and
recommendations for legislative or administrative action. For
the Program of Comprehensive Assistance for Family Caregivers,
VA is also required to report on outreach activities carried
out, in addition to an assessment of the manner in which
resources are expended.
Committee Bill. Section 303 would amend subparagraph
(A)(iv) of section 101(c)(2) of the Caregivers and Veterans
Omnibus Health Services Act of 2010 to require that VA's annual
evaluation report on the Program of Comprehensive Assistance
for Family Caregivers and the Program of General Caregiver
Support include a description of any barriers veterans or
caregivers experience in accessing and receiving care and
services. It would also amend subparagraph (B) of such section
to require that the report on the Program of Comprehensive
Assistance for Family Caregivers also include an evaluation of
the sufficiency and consistency of the training provided to
family caregivers. The additional information on barriers to
care and services and the sufficiency and consistency of
training will help further inform the Committee on the
effectiveness of the Program and potential issues that may need
to be addressed.
TITLE IV--APPROPRIATIONS OF AMOUNTS
Sec. 401. Appropriation of amounts for health care from Department of
Veterans Affairs.
Section 401 of the Committee bill, a freestanding original
provision, would provide $1 billion for the Secretary to
administer EDRP, increase the number of GME residency
positions, and allow for recruitment, retention and relocation
incentives as authorized under section 221 of the Committee
bill.
Background. Section 801 of P.L. 113-146, authorized and
appropriated $5 billion in funding to increase access to care
at VA facilities and improve the physical infrastructure of VA
facilities.
Committee Bill. Section 401(a) would provide $1 billion in
funding for the Secretary to administer EDRP, increase the
number of graduate medical education residency positions, and
implement section 221 of the Committee bill.
Section 401(b) would provide that the funds would be
available without fiscal year limitation. Section 401(c) would
direct that the funds be used to increase the number of
graduate medical education residency positions, and allow for
recruitment, retention and relocation incentives as authorized
under section 221 of the Committee bill. Section 401(d) would
direct that the Secretary provide the appropriate committees of
Congress with a funding plan describing how the Secretary would
intend to use the amounts appropriated in subsection 401(a).
Section 401(e) would make explicit that the funds provided in
subsection 401(a) are to supplement and not supplant other
funding provided to EDRP. Section 401(f) would direct the
Secretary to provide the appropriate committees of Congress
with a report describing how the Secretary has obligated the
amounts appropriated in subsection 401(a) as of the date of the
submission of the report. Section 401(g) would define the
appropriate committees of Congress.
Sec. 402. Appropriation of Amounts for the Veterans Choice Program.
Section 402 of the Committee bill, a freestanding original
provision, would provide an additional $4 billion for the
Veterans Choice Program.
Background. Section 101 of P.L. 113-146 authorized veterans
to receive care in the community if they would wait more than
30 days for care in a VA facility or lived more than 40 miles
from a VA facility. However, funding for care provided under
the Veterans Choice Program was tied to $10 billion in funding
provided in the Veterans Choice Fund as created by section 802
of P.L. 113-146. In July 2017, when VA indicated that the funds
for Veterans Choice Program were close to being depleted,
Congress provided an additional $2.1 billion in funding for the
Veterans Choice Program. In December 2017, after VA indicated
funds for the Veterans Choice Program would be depleted in
January 2018, Congress appropriated an additional $2.1 billion.
Committee Bill. Section 402(a) would provide an additional
$4 billion in funding for the Veterans Choice Program. Section
402(b) would direct that the funds would be available until
expended or the date specified in section 802(c)(4), December
31, 2018, as amended by section 142 of the Committee bill.
Committee Bill Cost Estimate
In compliance with paragraph 11(a) of rule XXVI of the
Standing Rules of the Senate, the Committee, based on
information supplied by the Congressional Budget Office
(hereinafter, ``CBO''), estimates that enactment of the
Committee bill would, relative to current law, increase
discretionary spending by $43.3 billion over 5 years and
increase mandatory spending by $5.6 billion over 10 years.
Enactment of the Committee bill would impose a governmental
mandate, as defined by the Unfunded Mandates Reform Act, that
would limit the application of State laws but would not result
in additional spending or any significant loss in revenue.
The cost estimate provided by CBO, setting forth a detailed
breakdown of costs, follows:
Congressional Budget Office,
Washington, DC, January 17, 2018.
Hon. Johnny Isakson,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 2193, the Caring for
Our Veterans Act of 2017.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Ann E.
Futrell.
Sincerely,
Keith Hall,
Director.
Enclosure.
S. 2193--Caring for Our Veterans Act of 2017
Summary: S. 2193 would increase the use of community health
care and long-term care by the Department of Veterans Affairs
(VA) by broadening eligibility for such care and allowing VA to
enter into agreements with health care providers in the private
sector without complying with the Federal Acquisition
Regulation (FAR). The bill also would make changes to VA's
health care programs and compensation of employees, including
expanding the caregivers program, increasing pay for employees,
and reimbursing medical staff for professional training. In
total, CBO estimates that implementing the bill would cost
$43.3 billion over the 2018-2022 period, assuming appropriation
of the necessary amounts.
In addition, S. 2193 would directly appropriate $4 billion
for the Veterans Choice Program (VCP) and $1 billion to provide
educational assistance for health professionals at VA. The bill
also would expand VA's authority to enter into leases for
medical facilities. In total, CBO estimates that enacting the
bill would increase direct spending by $5.6 billion over the
2018-2027 period.
Pay-as-you-go procedures apply because enacting S. 2193
would affect direct spending. Enacting the bill would not
affect revenues.
CBO estimates that enacting S. 2193 would not increase net
direct spending or on-budget deficits by more than $2.5 billion
in any of the four consecutive 10-year periods beginning in
2028.
S. 2193 would impose an intergovernmental mandate as
defined in the Unfunded Mandates Reform Act (UMRA) by
preempting state laws that prohibit VA physicians from
practicing telemedicine to treat veterans across state lines.
Although it would limit the application of state regulations,
the bill would impose no duty on state governments that would
result in additional spending or any significant loss of
revenues.
The bill contains no private-sector mandates as defined in
UMRA.
Estimated cost to the Federal Government: The estimated
budgetary effects of S. 2193 are shown in Table 1. The costs of
this legislation fall within budget function 700 (veterans
benefits and services).
Table 1.--Estimated Budgetary Effects of S.2193, The Caring for Our Veterans Act of 2017
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
---------------------------------------------------------------------------------------------
2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2018-2022 2018-2027
--------------------------------------------------------------------------------------------------------------------------------------------------------
INCREASES IN SPENDING SUBJECT TO APPROPRIATION
Estimated Authorization Level............................. 811 7,300 9,880 12,966 15,642 N/A N/A N/A N/A N/A 46,599 N/A
Estimated Outlays......................................... 638 6,342 9,213 12,249 14,895 N/A N/A N/A N/A N/A 43,337 N/A
INCREASES IN DIRECT SPENDING
Estimated Budget Authority................................ 5,000 0 0 140 140 140 140 140 140 140 5,280 5,980
Estimated Outlays......................................... 558 3,599 145 169 197 247 284 118 132 132 4,668 5,581
--------------------------------------------------------------------------------------------------------------------------------------------------------
N/A = not applicable.
Basis of estimate: For this estimate, CBO assumes that the
bill will be enacted near the beginning of calendar year 2018
and that the estimated amounts will be appropriated each year.
Estimated outlays are based on historical spending patterns for
the affected programs.
Spending subject to appropriation
CBO estimates that implementing S. 2193 would cost $43.3
billion over the 2018-2022 period, subject to appropriation of
the necessary amounts (see Table 2). Most of the bill's
estimated costs stem from provisions that would expand
community health care for veterans, increase eligibility and
benefits for caregivers, and increase pay for medical staff.
Veterans Community Care Program. Section 101 would
establish the Veterans Community Care Program (VCCP) under
which VA would be required to enter into contracts to establish
networks of health care providers outside of VA to furnish
hospital care, medical services, and extended-care services to
veterans enrolled in the VA health care system.
Table 2.--Estimate of the Effects on Spending Subject to Appropriation of S.2193, The Caring for Our Veterans
Act of 2017
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
--------------------------------------------------
2018 2019 2020 2021 2022 2018-2022
----------------------------------------------------------------------------------------------------------------
INCREASES IN SPENDING SUBJECT TO APPROPRIATION
Veterans Community Care Program
Estimated Authorization Level............................ 200 1,900 3,800 5,600 7,000 18,500
Estimated Outlays........................................ 200 1,700 3,500 5,300 6,600 17,300
Veterans Care Agreements
Estimated Authorization Level............................ * 4,400 4,500 4,700 4,800 18,400
Estimated Outlays........................................ * 3,800 4,300 4,500 4,700 17,300
Expansion of Family Caregivers Program
Estimated Authorization Level............................ 11 12 341 1,069 1,968 3,401
Estimated Outlays........................................ 10 11 298 962 1,815 3,096
Pay Caps for Nurses
Estimated Authorization Level............................ 400 480 580 680 790 2,930
Estimated Outlays........................................ 350 460 550 650 760 2,770
Walk-In Clinics
Estimated Authorization Level............................ * 82 170 333 438 1,023
Estimated Outlays........................................ * 71 156 306 414 947
Agreements for State Veterans Homes
Estimated Authorization Level............................ 0 80 110 130 160 480
Estimated Outlays........................................ 0 70 100 130 150 450
Prompt Payment to Providers
Estimated Authorization Level............................ 3 55 68 89 111 326
Estimated Outlays........................................ 3 48 64 84 106 305
Shared Medical Facilities
Estimated Authorization Level............................ 100 100 100 107 107 514
Estimated Outlays........................................ 4 19 49 75 91 238
Staffing Vacant Medical Positions
Estimated Authorization Level............................ 15 59 54 56 58 242
Estimated Outlays........................................ 13 53 53 54 57 230
Reimbursement for Education of Nurses
Estimated Authorization Level............................ 34 34 34 34 34 170
Estimated Outlays........................................ 30 33 33 33 33 162
Transplant Donors
Estimated Authorization Level............................ 2 17 35 47 49 150
Estimated Outlays........................................ 2 15 32 44 47 140
Compensation for Medical Directors
Estimated Authorization Level............................ 0 16 21 26 29 92
Estimated Outlays........................................ 0 14 20 25 28 87
Modify Threshold for Major Medical Facilities
Estimated Authorization Level............................ 16 16 16 36 36 120
Estimated Outlays........................................ 1 3 8 28 32 72
Mobile Deployment Teams
Estimated Authorization Level............................ 6 10 15 20 26 77
Estimated Outlays........................................ 5 9 14 19 25 72
Podiatrists
Estimated Authorization Level............................ 9 10 10 12 13 54
Estimated Outlays........................................ 8 10 10 12 13 53
Peer Specialist Program
Estimated Authorization Level............................ 4 9 9 10 10 42
Estimated Outlays........................................ 3 8 9 10 10 40
Demonstration Program on Dental Care
Estimated Authorization Level............................ 4 5 5 5 6 25
Estimated Outlays........................................ 3 5 5 5 6 24
Pilot Program for Tuition Reimbursement
Estimated Authorization Level............................ 4 4 4 5 5 22
Estimated Outlays........................................ 3 4 4 5 5 21
Coordinated-Care Program
Estimated Authorization Level............................ 0 5 5 5 0 15
Estimated Outlays........................................ 0 4 5 5 1 15
Pay for Perfusionists
Estimated Authorization Level............................ 1 1 1 1 1 5
Estimated Outlays........................................ 1 1 1 1 1 5
Studies, Reports, and Training
Estimated Authorization Level............................ 2 5 2 1 1 11
Estimated Outlays........................................ 2 4 2 1 1 10
--------------------------------------------------
Total Changes in Spending Subject to Appropriation
Estimated Authorization.............................. 811 7,300 9,880 12,966 15,642 46,599
Estimated Outlays.................................... 638 6,342 9,213 12,249 14,895 43,337
----------------------------------------------------------------------------------------------------------------
* = less than $500,000.
Under this program, subject to appropriations, VA would be
required to provide care through those networks, at the
veteran's discretion, in the following situations:
VA does not offer the care needed,
The veteran resides in New Hampshire, or
The veteran, as of the day before enactment, lives
40 miles away from a VA medical facility.
VA also would be required to provide such community care if
the veteran's primary care provider and the veteran agree it is
in the best medical interest of the veteran to do so, based on
criteria to be developed by VA that consider the nature and
frequency of the needed care and how accessible that care is to
the veteran. In addition, VA would be authorized to offer
community care if it determines that a VA medical center is not
meeting the standards for timeliness and quality that would be
developed by the department for different types of care.
Section 101 would require VA to promulgate regulations to
implement the program within 1 year.
The VCCP would replace an existing program that authorizes
VA to provide community care to veterans with service-connected
disabilities (SCDs) when VA does not offer the needed care or
when that care is geographically inaccessible to the veteran
and to women veterans who need hospital care. Under its
existing program, VA currently spends roughly $9 billion a year
for community care (excluding emergency care). CBO expects the
VCCP could cost several times more than the existing program
although several factors would limit the rate and ultimate
extent of cost growth. Cost would be higher because:
VA would be required, subject to appropriations,
rather than authorized to provide community care,
The number of eligible veterans would be several
times larger than the number eligible for the current program,
The criteria for offering community care would be
broader, and
The convenience of community care could encourage
more veterans to enroll in the VA health care system.
However, CBO expects these factors would limit the rate and
ultimate extent of cost growth:
A greater number of enrolled veterans receiving
community care could shorten wait times for care provided in VA
facilities, and thus reduce the number of veterans that need to
be referred to community care because VA care is not available
in a timely fashion.
Many of the regulations that need to be written to
implement the program could curtail use. For instance, VA would
probably require all veterans to be seen by a VA caregiver
before being referred for community care.
The community care networks could be limited in
size and scope, particularly in more rural areas, reducing the
accessibility of such care.
VA might implement the program slowly, as happened
with the VCP.
To estimate the cost of this program over the next 5 years,
CBO focused primarily on the extent to which the number of
veterans eligible for VCCP would be larger than those eligible
for the existing community care program. The currently eligible
population--veterans with SCDs and women veterans needing
hospital care--represents about 30 percent of enrolled
veterans. Under VCCP, the eligible population would more than
triple because all enrolled veterans would be eligible.
After accounting for the factors that might restrict use,
CBO estimates that in the early years of the program, the newly
eligible population would use community care at about half the
rate of veterans in the current community care program. In
addition, CBO expects that the program would be implemented
gradually. On that basis, CBO estimates that implementing
section 101 would cost $17.3 billion over the 2018-2022 period.
Veterans Care Agreements. Section 102 would allow VA to
enter into Veterans Care Agreements with health care providers
in the community to provide hospital care, medical services, or
extended care to eligible veterans. Such agreements would:
Exempt VA from using the competitive bidding
procedures as required under the FAR,
Require VA to verify that those community
providers meet the conditions for certification, and
Require VA to periodically review the necessity of
the agreements.
Under current law, VA must comply with the FAR for
agreements and contracts with community health care and
extended-care providers. The FAR is an extensive and complex
set of rules governing the federal government's purchasing
processes. According to VA, the FAR's requirements are
appropriate for large and long-term agreements for contracted
health care services but may not be practical for case-by-case
arrangements in all regions of the United States. This bill
would allow VA to use other agreements for certain health care
services and extended care provided outside the VA system.
For 2018, the Congress has provided roughly $10 billion for
community health care at VA (excluding the VCP). Using
information from VA, CBO estimates that implementing section
102 would give VA the legal authority to continue to provide
about 40 percent (or $4 billion annually) of that community
health care. After adjusting for inflation and accounting for
existing appropriations, CBO estimates that implementing this
section would cost $17.3 billion over the 2018-2022 period.
Expansion of the Family Caregivers Program. Section 301
would expand access to the Family Caregivers Program, which
provides stipends, health insurance, respite care, training,
and other forms of support to caregivers of eligible veterans
enrolled in the program. Veterans are eligible for the program
if they require assistance in activities of daily living, such
as bathing, eating, or grooming, as a result of injuries
incurred during military service on or after September 11,
2001. Section 301 would open that program in two stages to
eligible veterans of any era and would expand its benefits to
include legal and financial-planning services. In total, CBO
estimates that implementing section 301 would cost $3.1 billion
over the 2018-2022 period.
Under stage one, eligible veterans who were injured during
service on or before May 7, 1975, could enter the Family
Caregivers Program. That stage would begin within 2 years of
enactment (after VA develops and certifies a new information
technology [IT] system to track benefits, as required under
section 302). Stage two would begin 2 years after stage one and
would open the program to the remaining eligible veterans--
those injured during service after May 7, 1975, and before
September 11, 2001. For the purposes of this estimate, CBO
assumes that the bill will be enacted near the beginning of
calendar year 2018, that stage one of the proposal will begin
early in 2020, and that stage two will begin early in 2022.
In 2016, costs for the Family Caregivers Program totaled
$493 million, about $19,000 per participating veteran. Most of
that cost resulted from monthly stipends paid to caregivers.
Stipends are based on the hours of daily care the veteran
requires and the prevailing wage for home health aides. In
2016, the annual stipends paid under the program ranged from
$7,800 to $30,000 and averaged roughly $20,000. Caregivers also
are eligible to participate in the Civilian Health and Medical
Program of the Department of Veterans Affairs (CHAMPVA), a
program run by VA that provides health insurance for dependents
and survivors of certain disabled veterans. In addition, the
Family Caregivers Program provides up to 30 days of respite
care each year as well as training and 15 other support
services. In 2016, costs under the Family Caregivers Program
for CHAMPVA and the remaining services averaged about $2,600
per veteran.
CBO's estimate of the cost of expanding the caregivers
program is based on the patterns of use and the average costs
of the existing program and the number of veterans with
significant, service-connected disabilities in the cohorts that
would be newly eligible. Furthermore, to account for the
advanced age of the newly eligible veterans, the estimate
reflects the following findings from a 2014 RAND study:\1\
---------------------------------------------------------------------------
\1\Rajeev Ramchand and others, Hidden Heroes: America's Military
Caregivers (RAND Corporation, 2014), www.rand.org/pubs/
research_reports/RR499.html.
Disabled veterans rely more heavily on assistance
for daily activities as they age,
Older veterans tend to rely on older caregivers,
and
Health care costs for caregivers increase with
age.
For stage one, CBO estimates that about 22,000 additional
veterans would participate in the program in 2020, increasing
to roughly 46,000 by 2022. CBO expects that the youngest would
be in their late 60s. After factoring in a heavier reliance on
caregiver assistance for activities of daily living and higher
health care costs for an older group of caregivers, CBO
estimates that the average cost per participant in 2020 would
be about $30,500. However, VA already provides respite care to
assist some caregivers through its General Caregiver Program,
which provides limited support services to caregivers of
eligible veterans from all eras. Accounting for those current
benefits in the estimate reduces the average added cost per
participant to $30,000. After accounting for gradual
implementation and incorporating annual inflation, CBO
estimates that stage one of the proposal would cost $2.6
billion over the 2020-2022 period.
For stage two, CBO estimates that about 30,000 additional
veterans would use the Family Caregivers Program in 2022.
Because those veterans would be younger than the group under
the initial expansion, they would have less need for caregiver
assistance (with a correspondingly lower stipend amount) and
the caregivers would be younger (and have lower CHAMPVA costs).
After accounting for existing benefits under the General
Caregiver Program, the average incremental cost per participant
in 2022 would be $29,000, about 12 percent lower than the cost
for participants under stage one in that year. After factoring
in a gradual implementation for the second stage of expansion
and incorporating annual inflation, CBO estimates that the
additional costs for stage two of the Family Caregivers Program
would be $417 million in 2022. Those costs would rise to
billions of dollars a year by the end of the 10-year window,
CBO estimates.
In addition, CBO estimates that roughly 30,000 caregivers
in the current Family Caregivers Program (for veterans injured
during service on or after September 11, 2001) would receive
legal and financial support services. On the basis of the
resources necessary to provide counseling under the existing
program, CBO estimates an average annual cost of $130 per
beneficiary for legal and financial services. CBO estimates a
cost of $15 million over the 2018-2022 period to provide those
benefits to individuals eligible for the Family Caregivers
Program under current law. The costs of providing that
additional benefit for newly eligible enrollees in the Family
Caregivers Program under this provision are included in the
estimates above for adding those people to the program.
Furthermore, in anticipation of the surge of new
applications upon expansion of the Family Caregivers Program,
VA would need to hire and train additional staff to manage the
program (to staff a caregiver support line, provide outreach,
and monitor the program). On the basis of program data from
2014 and adjusting for inflation, CBO estimates overhead costs
of about $400 per participant to process 22,000 new
applications starting in 2020. As a result, CBO estimates the
additional overhead costs would be $17 million over the 2018-
2022 period.
Pay Caps for Nurses. Section 224 would increase the maximum
rate of pay for registered nurses at VA to executive level III
($172,100 in 2017) from the current maximum of executive level
IV ($161,900 in 2017)--an increase of 6.3 percent. VA employs
roughly 68,000 registered nurses. CBO expects that such a
change would result in average pay for registered nurses
increasing by that same percentage, from $89,000 to $94,600 in
2017. In addition, the higher pay level could help ameliorate
VA's current difficulties in recruiting and retaining
registered nurses and would thus increase the total number of
nurses employed by VA. Using data from VA on hiring and
retaining nurses, CBO estimates that, under section 224, VA
would employ roughly 71,000 registered nurses by 2022 (or a 4
percent increase above current staffing). On that basis, CBO
estimates that implementing section 224 would cost $2.8 billion
over the 2018-2022 period for increased compensation for
registered nurses.
Section 224 also would increase the maximum rate of pay for
nurse executives at VA to executive level I ($207,800 in 2017)
from the current maximum of executive level IV ($161,900 in
2017)--an increase of 28 percent. VA employs about 160 nurse
executives at average salaries of $136,995. CBO expects that VA
would gradually increase the salaries of the nurse executives
to reach a 28 percent increase, on average, by 2022. As a
result, CBO estimates that increasing the cap for nurse
executives would cost $16 million over the 2018-2022 period. In
total, CBO estimates that implementing section 224 would cost
$2.8 billion over the 2018-2022 period.
Walk-In Clinics. Within a year of enactment, section 105
would require VA to provide access to walk-in clinics operated
by non-VA entities for veterans actively using the VA health
care system. For their first two visits to a private clinic in
any year, veterans' copayments would be limited to the amount,
if any, required at VA facilities, as determined by the
department. For subsequent visits, the veterans would be
required to make copayments in an amount set by the department.
Using information from VA, CBO estimates that the
department would reimburse about 2.7 million claims for visits
to walk-in clinics each year, at an average of $200 per visit.
After adjusting for time to prepare the regulations and a
gradual implementation, CBO estimates that implementing section
105 would cost $947 million over the 2018-2022 period.
Agreements for State Veterans Homes. Section 103 would
waive the requirements of the FAR for contracts and agreements
that VA enters into with state-run nursing homes for veterans.
Under current law, the state veterans' homes (SVHs) must fill
75 percent of their beds with veterans. VA pays SVHs the full
cost of care for veterans with an SCD rating of 70 percent or
more, under a contract or agreement. For all other veterans, VA
pays SVHs a grant based on a fixed daily allowance.
According to VA, in 2015 the department used such
agreements to reimburse state-run nursing homes at a daily rate
of $380 for each veteran with an SCD of 70 percent or more--at
an annual cost of roughly $350 million (or 37 percent of the
total reimbursed to SVHs). However, those agreements do not
comply with the FAR, and VA does not expect to be able to enter
into new FAR agreements with any of the SVHs. In the absence of
this legislation, CBO expects that VA would gradually phase out
the use of such agreements as veterans who are currently under
that payment structure die or leave the SVHs. Those veterans
would probably be replaced by veterans under the lower daily
allowance rate of roughly $100 per patient. By allowing VA to
enter into agreements outside of the FAR framework, CBO
estimates, this proposal would nearly triple VA's
reimbursements to SVHs for veterans with SCDs of 70 percent or
more.
As a result, after factoring in a gradual phase out of
existing non-FAR agreements, CBO estimates that enacting this
provision would cost $450 million over the 2018-2022 period.
The additional costs from waiving the FAR requirements would
begin in 2019. Because appropriations have already been
provided for such agreements in 2018, we estimate no additional
funding would be necessary in that year.
Prompt Payment to Providers. Section 111 would establish
standards for prompt payment of claims for reimbursement for
health care provided to veterans in the community, and it would
require VA to enter into a contract or agreement with a
nondepartment entity to process those claims. In total, CBO
estimates, implementing this section would cost $305 million
over the 2018-2022 period.
Expedited Processing of Claims. Currently, department
standards require VA to process 90 percent of claims for
reimbursement of non-VA health care within 30 days. However, VA
has been unable to meet such standards. Under section 111, VA
would be required to reimburse non-VA providers within 30 to 45
days of receiving a completed claim form. On the basis of a
report by the Government Accountability Office and information
from VA, CBO estimates that the department would need 340
additional claims processors at an average annual compensation
of $51,000 to meet the expedited time frame for reimbursing
existing non-VA health care. After factoring in the period for
VA to prepare regulations in 2018, CBO estimates that
expediting the processing of claims for such health care would
cost $62 million over the 2018-2022 period.
Contracted Claims Processors. Section 111 also would
require VA to outsource the processing of claims for non-VA
health care. Currently, VA employs about 2,000 claims
processors for that purpose at an average compensation of
$51,000. CBO expects that the costs for using contractors
rather than VA employees would be the same; therefore, no
additional costs are estimated for replacing existing VA claims
processors with contractors.
Upon entering into contracts for claims processors, CBO
expects that VA would offer current existing claims processors
the following options:
Accept placement in another vacant local position
at VA,
Relocate to a position that already exists in
another VA location, or
Voluntarily separate from VA employment.
CBO estimates that placing one-third (or about 600) of the
claims processors in other local positions would present
minimal costs for administrative duties to select and train the
staff. CBO expects that the other two-thirds (about 1,100
claims processors) would relocate or voluntarily end their
employment at VA. Using information from VA, CBO estimates that
the average cost for relocation or incentive payments for
voluntary separation would be $20,000 per employee. As a
result, CBO estimates that relocating or ending employment for
VA claims processors would cost $24 million over the 2019-2020
period.
Processing New Claims. In order to handle the additional
claims of the VCCP established under section 101 of the
legislation, CBO estimates that VA would gradually expand the
contract discussed above to account for the more than doubling
of non-VA health care. By 2022, an additional 2,230 processors
would be needed at an average annual compensation of $51,000.
After factoring in a gradual implementation of the program,
adding those claims processors would cost about $220 million
over the 2018-2022 period.
Shared Medical Facilities. Section 242 would allow VA to
enter into agreements with other federal departments to
construct shared medical facilities.
Implementing this section could reduce VA's share of the
cost of some construction projects and some projects would no
longer require legislative authorization. Using information
from VA, CBO estimates that the total cost for such major
construction projects would average about $100 million each
year. On that basis, CBO estimates costs of $225 million over
the 2018-2022 period for additional construction projects.
Section 242 also would expand VA's authority to enter into
leases for medical facilities. CBO estimates that VA would
enter into one additional lease each year, with a total annual
rent payment of $3 million. For those leases, VA would record
obligations of $7 million each year as it enters those
contracts at a cost of $13 million over the 2021-2022 period
for additional leases. Entering into those leases also would
increase direct spending; which is discussed below under the
heading ``Direct Spending.''
In total, CBO estimates section 242 would cost $238 million
over the 2018-2022 period.
Staffing Vacant Medical Positions. Within 180 days of
enactment, section 206 would require VA to identify and fill
vacant positions in the areas of mental health care (such as
psychologists, psychiatrists, and additional therapists and
counselors) and staff on Patient Aligned Care Teams or PACTs
(such as mental health professionals and primary care
physicians). PACTs use a team-based model of care to address
the comprehensive needs of patients receiving health care at VA
medical centers.
VA has advertised vacant positions for mental health
professionals and primary care physicians. CBO estimates about
130 vacant positions for mental health professionals and 130
positions for primary care physicians in PACTs would be filled
under this section. Using information from VA, CBO expects an
average compensation of $120,000 for a mental health care
provider and $220,000 for a primary care physician in 2018. VA
would probably need to offer special recruitment incentives
(such as hiring bonuses) to meet the hiring deadline under this
proposal. Under current law, VA offers up to 25 percent of the
rate of basic pay as a recruitment bonus. Such onetime bonuses
would amount to roughly $23,000 for mental health providers and
$43,000 for physicians. After accounting for the expected
growth in wages, CBO estimates that implementing this section
would cost $230 million over the 2018-2022 period.
Reimbursement for Education of Nurses. Section 213 would
require VA to reimburse nurses for up to $1,000 of the cost of
continuing professional education. Under current law, VA is
only required to reimburse physicians and dentists for such
costs. However, the department currently reimburses registered
nurses an average of $500 per year. VA employs roughly 68,000
registered nurses. CBO estimates that this provision would
increase reimbursement for continuing professional education by
$500 per nurse, on average. As a result, CBO estimates that
implementing this section would cost $162 million over the
2018-2022 period.
Transplant Donors. Section 252 would allow VA to cover
costs related to organ transplant procedures for veterans and
their living donors at nondepartment facilities. Currently, VA
covers the medical and service expenses (such as transportation
and lodging) for veterans and their living donors only for
procedures performed at the Department of Veterans Affairs
Transplant Centers (VATCs). For procedures that take place at
nondepartment facilities, VA reimburses donors only for
transportation and lodging. In 2017, VA provided 560 organ
transplants, most of which occurred at VATCs. Of those
operations, about 200 were for kidney transplants and about 20
were with living donors.
Section 252 would authorize VA to pay for transplant
procedures at various locations nationwide with minimal out-of-
pocket expenses for veterans and their living donors. As a
result, CBO expects more veterans would use VA for such
procedures and more people would be willing to donate organs.
In determining the additional number of transplant procedures,
CBO considered the other sources of health care coverage
carried by enrolled veterans and the likelihood, under this
proposal, that those veterans would instead use VA for their
transplant procedures.
Using information from the Census Bureau, VA, and the
Department of Health and Human Services (HHS), CBO estimates
that under this section roughly 60 additional veterans would
undergo transplants at nondepartment facilities each year, at
an average cost of $750,000 per patient. CBO estimates that VA
would cover the medical expenses of an additional 50 living
donors (some for procedures that will occur under current law
but for which VA would not pay medical expenses) each year, at
an average cost of $80,000 per donor. In addition, CBO believes
that implementing this section would allow veterans to undergo
transplants closer to home. As a result, CBO estimates a
reduction in costs for transportation reimbursements of about
$4 million each year. Based on the expectation that VA would
implement the bill gradually, CBO estimates that implementing
section 252 would have a net cost of $140 million over the
2018-2022 period.
Compensation for Medical Directors. Section 205 would
remove the cap on basic pay for directors of regional and
medical facilities at the department. Under current law, the
salary for those positions is capped at level V of the
executive schedule. CBO expects that this section would allow
VA to offer competitive pay (based on compensation in the
private market) for those positions. VA employs about 130
directors at an average compensation amount of $282,000 in
2017. On average, compensation for medical directors in the
private sector is about $320,000. As a result of the increase
in salary, CBO estimates that VA would be able to fully staff
the 140 medical director positions by 2021. After factoring in
a 1-year delay and additional hiring, CBO estimates that
implementing this provision would cost $87 million over the
2018-2022 period.
Modify Threshold for Major Medical Facilities. Section 241
would expand the authority of VA to construct and lease medical
facilities.
Section 241 would allow VA to construct medical facilities
with total costs of up to $20 million without legislative
authorization. Under current law, VA must receive legislative
authorization to construct medical facilities with total
expenses above $10 million.
Using information on planned construction projects in VA's
2018 budget submission, CBO estimates that implementing this
section would authorize one additional construction project
each year with an average cost of $16 million. On that basis,
CBO estimates costs of $36 million over the 2018-2022 period
for construction of new facilities.
In addition, this section would expand VA's authority to
enter into leases for medical facilities. CBO estimates that VA
would enter into six additional leases each year with a total
annual rent payment of $7 million. In that case, VA would
record obligations of $20 million each year as it enters those
contracts at a cost of $36 million over the 2021-2022 period
for additional leases. CBO estimates that this authority also
would increase direct spending, which is discussed below under
the heading ``Direct Spending.''
In total, CBO estimates implementing section 241 would cost
$72 million over the 2018-2022 period.
Mobile Deployment Teams. Section 233 would require VA to
establish a program to provide mobile deployment teams of
medical personnel to provide health care at underserved VA
facilities. On the basis of costs in the private-sector to
operate mobile clinics, CBO estimates start-up costs of
$300,000 per team and annual costs to operate each mobile
clinic of $375,000. In addition, CBO estimates a medical team
of three physicians would cost $450,000 per clinic. CBO expects
that VA would implement this program gradually, starting with
five mobile deployment teams in 2018 and growing to 25 by 2022.
As a result, CBO estimates that implementing this section would
cost $72 million over the 2018-2022 period.
Podiatrists. Section 202 would add podiatrists to the same
pay schedule as physicians and dentists and thereby increase
their pay. Currently, VA employs about 400 podiatrists
nationwide at an average annual salary of about $130,000. On
the basis of information from VA about the average increase
necessary for podiatrists to move to a pay schedule comparable
to that of physicians and dentists, CBO estimates that the base
salary for podiatrists would increase by about 15 percent to
$150,000 in 2018. In addition, using data on hiring from VA,
CBO estimates that VA would be able to hire an additional 30
podiatrists because the increased pay would make working at VA
more attractive. After accounting for projected pay raises, CBO
estimates that implementing the provision would cost $53
million over the 2018-2022 period.
Peer Specialist Program. Section 208 would require that VA
establish a program to include at least two peer specialists in
PACTs to promote services for mental health, substance use
disorders, and behavioral health in primary care. The program
would require a rapid rollout, being implemented in at least 25
medical centers in 2018 and in at least 50 medical centers in
2019. CBO expects the department would implement the program in
two PACTs per medical center. Using information from VA, CBO
estimates that the 200 additional peer specialists by 2019
would receive an average salary of $41,000. After adjusting for
wage growth, CBO estimates that implementing this section would
cost $40 million over the 2018-2022 period.
Demonstration Program on Dental Care. Section 215 would
require VA to establish a demonstration program to increase
veterans' access to dental care that would require hiring and
training alternative dental health providers. Those employees
would include community dental health coordinators, advance
practice dental hygienists, independent dental hygienists,
supervised dental hygienists, primary care physicians, dental
therapists, dental health aides, and any other health
professionals that the Secretary determines appropriate.
Based on the scope of a similar demonstration program
operated by HHS, CBO expects that developing and operating the
program would require two additional full-time employees at
each facility to engage in research, training, and assessment
of the program. Based on the costs of similar proposals, CBO
expects this program would operate within 10 medical facilities
and that the annual cost per staff person would be $100,000 in
2018 and $11 million over the 2018-2022 period.
CBO expects that the use of alternative dental care
providers would increase VA's delivery of dental care to
veterans. CBO estimates VA would hire two additional dental
health providers at each of the 10 medical facilities at an
average compensation of $150,000. As a result, CBO estimates
that hiring additional dental health providers would cost $14
million over the 2018-2022 period.
In total, implementing section 215 would cost $24 million
over the 2018-2022 period.
Pilot Program for Tuition Reimbursement. Section 232 would
require VA to carry out a 6-year pilot program to repay the
education loans of certain physicians. Eligible physicians
would include those who are licensed as well as those in their
last year of residency who agree to work at VA for a certain
period in rural locations. The department would be required to
select employees in at least three medical centers and seven
ambulatory care facilities.
The program would pay up to the full amount of the medical
loans for newly licensed physicians and up to $50,000 of loans
for current physicians at VA. For this estimate, CBO expects
that VA would repay the loans of 50 physicians in each year of
the pilot program, and that one-third of the participants would
be newly licensed physicians and two-thirds would be
established physicians at VA. Based on information from the
National Center for Education Statistics and the Association of
American Medical Colleges, newly licensed physicians would have
an estimated average education loan debt of $170,000 in 2017.
For established physicians, CBO expects that VA would reimburse
about $40,000 of their student loan debt. After factoring in
the growth in costs for higher education, CBO estimates that
implementing the pilot program would cost $21 million over the
2018-2022 period.
Coordinated-Care Program. Section 251 would require VA to
provide grants to certain public or nonprofit entities. Grant
recipients would coordinate wellness care for veterans
receiving mental health care from VA. The grantees also would
assess the usefulness of coordinating such care and report on
that assessment. That program would begin a year after
enactment and continue for 3 years.
Based on VA's implementation of other programs of similar
scope (such as using meditation for veterans with Post
Traumatic Stress Disorder), CBO expects that VA would award
grants to coordinate care at 10 VA medical facilities and that
each grant would cover the costs of about four employees to
deliver services and analyze and report to the Congress on the
results of their efforts. CBO estimates that the average
compensation for those employees would be about $120,000 in
2018. In total, after accounting for inflation, CBO estimates
the cost to implement the program would be $15 million over the
2018-2022 period.
Pay for Perfusionists. Section 203 would increase the
maximum salary for perfusionists employed by VA by exempting
them from certain salary limitations. (Perfusionists are
medical professionals responsible for operating heart-lung
machines during cardiac surgery.) Currently VA employs 28
perfusionists (in the 41 VA medical facilities offering the
type of cardiac surgery requiring such services) at an average
salary of $101,000. On the basis of information from VA, CBO
estimates that implementing this proposal would increase the
salary of perfusionists at the department by 18 percent. As a
result, CBO also expects that VA would see higher retention and
recruitment for this position, resulting in a 20 percent
increase in staff--an additional 6 perfusionists by 2022. In
total, CBO estimates that implementing this section would cost
$5 million over the 2018-2022 period.
Studies, Reports, and Training. S. 2193 would require VA to
conduct studies, issue reports, and provide training for staff.
Based on the costs of similar activities, CBO estimates that
meeting those requirements would cost $10 million over the
2018-2022 period.
By December 31, 2018, section 302 would require VA
to develop and implement an IT system to track and assess data
from the Family Caregiver Program. VA reports that it is
currently working to enhance its existing IT system for
tracking caregivers to allow for an easier application process
and for tracking stipend awards and other benefits. As a
result, CBO estimates that this requirement would mostly codify
existing practice and would have no budgetary effect. However,
the provision also includes assessment and reporting
requirements that CBO estimates would cost $2 million over the
2018-2022 period.
Section 104 would require that VA establish
benchmark guidelines for access to health care at VA medical
facilities. Such guidelines would assist medical providers on
whether to refer veterans into the community for health care.
The section also would establish quality standards for health
care at the department. CBO estimates that this section would
cost $1 million over the 2018-2022 period.
Starting in 2019 and every 2 years thereafter,
section 106 would require that VA conduct market area
assessments on the health care services provided by the
department. Every 4 years, this section also would require VA
to develop a strategic plan to meet the demand for health care
provided by the department. CBO estimates that implementing
this section would cost $1 million over the 2018-2022 period.
Other provisions, including sections 108, 121,
122, 123, 201, 207, and 222 would require periodic reports on
education and training programs, personnel, telemedicine, and
performance awards and bonuses for employees at VA.
Furthermore, section 231 would require VA to develop criteria
to assess underserved facilities. In total, CBO estimates that
those reports and criteria would cost $6 million over the 2018-
2021 period.
Direct spending
S. 2193 would appropriate funds for the Veterans Choice
Program and for health care at VA. In addition, the bill would
increase VA's ability to lease medical facilities without
subsequent legislative authorization. On that basis, CBO
estimates that the legislation would increase direct spending
by $5.6 billion over the 2018-2027 period (see Table 3).
Veterans Choice Program. Section 402 would appropriate $4
billion for VCP, which pays for certain veterans to receive
health care from participating providers in the private sector.
For fiscal year 2018, VCP has about $4 billion in available
funds, which CBO estimates will be completely committed in
2018. Under current law, the program will terminate once its
funding is exhausted. CBO expects that enacting this provision
would extend the life of VCP through most of 2019. On that
basis, CBO estimates that section 402 would increase direct
spending by $4 billion over the 2018-2027 period.
Table 3.--Estimate of the Effects on Direct Spending of S.2193, T he Caring for Our Veterans Act of 2017
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-------------------------------------------------------------------------------------
2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2018-2022 2018-2027
--------------------------------------------------------------------------------------------------------------------------------------------------------
INCREASES IN DIRECT SPENDING
Veterans Choice Program
Budget Authority.............................................. 4,000 0 0 0 0 0 0 0 0 0 4,000 4,000
Estimated Outlays............................................. 500 3,500 0 0 0 0 0 0 0 0 4,000 4,000
Health Professionals Education Assistance Program
Budget Authority.............................................. 1,000 0 0 0 0 0 0 0 0 0 1,000 1,000
Estimated Outlays............................................. 58 99 145 163 170 178 187 0 0 0 635 1,000
Major Medical Facilities
Estimated Budget Authority.................................... 0 0 0 100 100 100 100 100 100 100 200 700
Estimated Outlays............................................. 0 0 0 4 19 49 69 84 94 94 23 413
Shared Medical Facilities
Estimated Budget Authority.................................... 0 0 0 40 40 40 40 40 40 40 80 280
Estimated Outlays............................................. 0 0 0 2 8 20 28 34 38 38 10 168
-------------------------------------------------------------------------------------
Total Changes in Direct Spending
Estimated Budget Authority................................ 5,000 0 0 140 140 140 140 140 140 140 5,280 5,980
Estimated Outlays......................................... 558 3,599 145 169 197 247 284 118 132 132 4,668 5,581
--------------------------------------------------------------------------------------------------------------------------------------------------------
Health Professionals Education Assistance Program. Section
401 would appropriate $1 billion for reimbursing employees at
VA for their professional education. Specifically, the
appropriations would be used to increase the number of graduate
medical residents at VA (under sections 202 and 203 of this
bill), increase bonuses and awards for VA employees (under
section 204), and increase the payments for reducing student
loan debt for certain VA staff (under section 213). CBO
estimates that the appropriated amounts would be sufficient to
fund those programs through 2024. Beyond that year, CBO
estimates that the increased program costs would continue,
subject to appropriation of the necessary amounts. CBO
estimates section 401 would increase direct spending by $1
billion over the 2018-2027 period.
Major Medical Facilities. Sections 241 would expand VA's
authority to enter into leases for medical facilities.
(Provisions also would expand the authority to construct
medical facilities, discussed above under the heading
``Spending Subject to Appropriation.'') In total, CBO estimates
that enacting this section would increase direct spending by
$413 million over the 2018-2027 period.
VA classifies its contracts for acquiring such facilities
as operating leases and thus records its obligations for lease
payments on an annual basis over the term of each lease.
However, CBO has reviewed several contracts and has concluded
that they are akin to government purchases of facilities built
specifically for VA's use--but instead of being financed by the
Treasury, they rely on third-party financing (that is, funds
raised by a nonfederal entity), which is generally more
expensive.\2\ That conclusion is based on those leases having
many of the following key features:
\2\For more information on the budgetary treatment of third-party
financing, see Congressional Budget Office, Third-Party Financing of
Federal Projects (June 2005), www.cbo.gov/publication/16554.
The facilities are designed and constructed to the
unique specifications of the government;
The facilities are constructed at the request of
the federal government;
The leases on the newly constructed facilities are
long term--usually 20 years;
Payments from the federal government are the only
or the primary source of income for the facilities;
The term of the contractual agreements coincides
with the term of the private partner's financing instrument for
developing and constructing the facility (that is, a facility
financed with a 20-year bond will have a 20-year lease term);
The federal government commits to make fixed
annual payments that are sufficient to service the debt
incurred to develop and construct the facility, regardless of
whether the agency continues to occupy the facility during the
guaranteed term of the lease; and
The fixed payments over the life of the lease are
sufficient to retire the debt for the facility.\3\
---------------------------------------------------------------------------
\3\See testimony of Robert A. Sunshine, Deputy Director,
Congressional Budget Office, before the House Committee on Veterans'
Affairs, The Budgetary Treatment of Medical Facility Leases by the
Department of Veterans Affairs (June 27, 2013), www.cbo.gov/
publication/44368.
Thus, although those transactions are structured as leases,
they are essentially government purchases. Under the normal
procedures governing the budgetary treatment of the purchase of
capital assets, budget authority should be available and
obligations should be recorded at the time the acquisitions are
initiated, and amounts recorded should equal the full
development and construction costs of the medical facilities.
Instead, VA records a small fraction of those costs as
obligations when it awards the contracts for such transactions.
To the extent that the full costs of developing and
constructing the facilities exceeds the relatively small amount
that VA would initially record as obligations against its
appropriation, CBO treats the legislative authorization for
those transactions as contract authority--a type of budget
authority that allows an agency to enter into a contract and
incur an obligation before receiving an appropriation for those
activities. Because the contract authority would be provided in
an authorizing bill, rather than in an appropriation act, the
resulting spending is categorized as direct spending (as
distinguished from discretionary spending, which results from
appropriation acts).
In addition, at the time the contracts are signed, VA
typically obligates some amounts from available appropriations;
those costs are considered discretionary.
Section 241 would allow VA to enter into leases without
legislative authorization for medical facilities with annual
lease payments of up to $1.5 million. Under current law, VA
must receive legislative authorization to lease medical
facilities with annual rent payments in excess of $1 million.
After reviewing VA's 2018 budget request for leases of
medical facilities, CBO estimates that enacting this provision
would allow VA to enter into six additional leases, on average,
each year. In total, the annual rent payments for those leases
would be about $7 million. CBO expects that the initial
contracts for those facilities would be entered into starting
in 2021 and that similar contracts would be signed each year
thereafter.
When the government leases a facility the lessor charges
the government for the cost to construct the facility plus
interest on those costs over the period it takes to recover
them through the lease payments. CBO's estimate of direct
spending reflects an amount equal to the cost of constructing
the facilities, plus the net present value of the portion of
lease costs attributable to interest rates that would exceed
U.S. Treasury interest rates. (Borrowing costs equivalent to
the amount of Treasury interest that would be paid if the
equipment was financed with appropriated funds are not included
in our estimate because, for the enforcement of Congressional
budget rules, changes in Treasury interest costs are not
counted as a cost or savings related to any particular
legislative provision.) CBO's estimate of outlays reflects its
judgment as to when the facilities would be provided--typically
over a 6-year period.
On that present value basis for each lease over the term of
the lease agreement, CBO estimates that enacting this provision
would increase direct spending by $413 million over the 2021-
2027 period.\4\
---------------------------------------------------------------------------
\4\A present value is a single number that expresses a flow of past
and future income or payments in terms of an equivalent lump sum
received or paid today. The value depends on the rate of interest,
known as the discount rate, used to translate past and future cash
flows into current dollars. CBO calculated costs for the 20-year leases
by discounting the expected annual rent payments using the rate on
Treasury securities of comparable maturity.
---------------------------------------------------------------------------
Shared Medical Facilities. Section 242 would allow VA to
enter into sharing agreements with other federal agencies to
lease medical facilities. VA's portion of the annual rent
payments for leased medical facilities could be lowered by
enough that some leases would no longer require legislative
authorization. Using information from VA, CBO estimates that,
on average, this section would allow construction of one
medical facility each year with an average annual rent payment
of $3 million. CBO expects that VA would enter into the first
such contract in 2021 and that similar contracts would take
effect each year thereafter. On a present value basis for each
lease over the term of the lease agreement, CBO estimates that
enacting this section would increase direct spending by $168
million over the 2021-2027 period.
Pay-As-You-Go Considerations: The Statutory Pay-As-You-Go
Act of 2010 establishes budget-reporting and enforcement
procedures for legislation affecting direct spending or
revenues. The net changes in outlays that are subject to those
pay-as-you-go procedures are shown in Table 4.
Table 4.--CBO Estimate of Pay-As-You-Go Effects of S.2193, The Caring for Our Veterans Act of 2017, as Ordered
Reported by the Senate Committee on Veterans' Affairs on November 29, 2017
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------------------------------------------
2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2018-2022 2018-2027
----------------------------------------------------------------------------------------------------------------
NET INCREASE IN THE ON-BUDGET DEFICIT
Statutory Pay-As-You-Go 558 3,599 145 169 197 247 284 118 132 132 4,668 5,581
Impact.....................
----------------------------------------------------------------------------------------------------------------
Increase in long-term direct spending and deficits
CBO estimates that enacting the draft bill would not
increase net direct spending or on-budget deficits by more than
$2.5 billion in any of the four consecutive 10-year periods
beginning in 2028.
Mandates
S. 2193 would impose an intergovernmental mandate as
defined in UMRA by preempting state laws that prohibit VA
physicians from practicing telemedicine to treat veterans
across state lines. Although it would limit the application of
state regulations, the bill would impose no duty on state
governments that would result in additional spending or any
significant loss of revenues.
The bill contains no private-sector mandates as defined in
UMRA.
Previous CBO estimates: On November 13, 2017, CBO
transmitted a cost estimate for H.R. 4243, the VA Asset and
Infrastructure Review Act of 2017, as ordered reported by the
House Committee on Veterans' Affairs on November 8, 2017.
Sections 201 and 204 in H.R. 4243 are similar to sections 241
and 242 of S. 2193 and the estimated costs for both sections
are the same.
On November 8, 2017, CBO transmitted a cost estimate for
H.R. 1133, the Veterans Transplant Coverage Act of 2017, as
ordered reported by the House Committee on Veterans' Affairs on
July 19, 2017. H.R. 1133 is similar to section 252 of S. 2193
and the estimated costs are the same.
On July 24, 2017, CBO transmitted a cost estimate for
H.R. 1058, the VA Provider Equity Act, as ordered reported by
the House Committee on Veterans' Affairs on July 19, 2017. The
language in H.R. 1058 that affects podiatrists is similar to
section 202 of S. 2193 and the estimated costs are the same.
Estimate prepared by: Federal Costs: Ann E. Futrell;
Mandates: Zachary Byrum.
Estimate approved by: H. Samuel Papenfuss, Deputy Assistant
Director for Budget Analysis.
Regulatory Impact Statement
In compliance with paragraph 11(b) of rule XXVI of the
Standing Rules of the Senate, the Committee on Veterans'
Affairs has made an evaluation of the regulatory impact that
would be incurred in carrying out the Committee bill. The
Committee finds that the Committee bill would not entail any
regulation of individuals or businesses or result in any impact
on the personal privacy of any individuals and that the
paperwork resulting from enactment would be minimal.
Tabulation of Votes Cast in Committee
In compliance with paragraph 7(b) of rule XXVI of the
Standing Rules of the Senate, the following is a tabulation of
votes cast in person or by proxy by members of the Committee on
Veterans' Affairs at its November 29, 2017, meeting. Twenty-two
amendments to the Committee Bill were voted on by members.
Chairman Isakson called up nineteen amendments to be
considered en bloc. The amendments were sponsored by Senators
Sullivan, Heller, Cassidy, Rounds, Sanders, Blumenthal, Moran,
Tillis, and Brown. The amendments were agreed to by voice vote.
An amendment by Senator Moran would have replaced sections
of the Committee Bill regarding community care, access and
quality standards, prompt pay, access to walk-in care, a
strategy for care provided by VHA, authorization of
appropriations for care provided in VHA, and the appropriation
of $4 billion for the Veterans Choice Program. In addition, the
amendment would have added provisions to the Committee Bill
relating to continuity of care, payment rates for care in the
community, and a center of innovation for care and payments.
This amendment was not agreed to by voice vote and Senator
Moran requested that he be recorded as voting aye.
An amendment by Senator Cassidy would have removed a
section of the Committee Bill that allowed veterans to file a
disability compensation claim for adverse medical events for
care received in the community. This amendment was not agreed
to by voice vote.
The Committee also discussed amendments sponsored by
Senator Sanders but did not vote on those amendments because
they were withdrawn.
The Committee Bill, as amended during the Committee
meeting, was agreed to by a roll call vote.
----------------------------------------------------------------------------------------------------------------
Nays Senator Yeas
----------------------------------------------------------------------------------------------------------------
X Mr. Moran
Mr. Boozman X
Mr. Heller X
Mr. Cassidy X
Mr. Rounds X
Mr. Tillis X
Mr. Sullivan X
Mr. Tester X
Mrs. Murray X
Mr. Sanders X
Mr. Brown X
Mr. Blumenthal X
Ms. Hirono X (by proxy)
Mr. Manchin X
Mr. Isakson, Chairman X
----------------------------------------------------------------------------------------------------------------
1 TALLY 14
----------------------------------------------------------------------------------------------------------------
Agency Reports
On May 17, 2017, Jennifer S. Lee, M.D., Deputy Under
Secretary for Health for Policy and Services, Veterans Health
Administration; on July 11, 2017, Baligh Yehia, M.D., Deputy
Under Secretary for Health for Community Care, Veterans Health
Administration from the Department of Veterans Affairs appeared
before the Committee on Veterans' Affairs and submitted
testimony on various bills incorporated into the Committee
bill. Excerpts from those statements are below:
STATEMENT OF DR. JENNIFER S. LEE, DEPUTY UNDER SECRETARY FOR HEALTH FOR
POLICY AND SERVICES VETERANS HEALTH ADMINISTRATION DEPARTMENT OF
VETERANS AFFAIRS
Good morning, Chairman Isakson, Ranking Member Tester, and
Members of the Committee. Thank you for inviting us here today
to present our views on several bills that would affect the
Department of Veterans Affairs' (VA) programs and services.
Joining me today is Ms. Margaret Kabat, National Director,
Caregiver Support Program, Veterans Health Administration
(VHA); Phil Parker; Acting Associate Deputy Assistant
Secretary, Office of Acquisition and Logistics, Office of
Acquisition, Logistics, and Construction (OALC); Mr. James
Ruhlman, Assistant Director for Policy & Procedures, Veterans
Benefits Administration (VBA); Ms. Meghan Flanz, Interim
General Counsel; Dave McLenachen, Director, Appeals Management
Office, VBA; and Donnie Hachey, Chief Counsel for Operations,
Board of Veterans Appeals (BVA).
There are a number of bills on the agenda today, and we are
unable at this time to provide views and cost estimates on a
few of these provisions. Specifically, we do not have cost
estimates on S. 543 and S. 764.
S. 591--MILITARY AND VETERAN CAREGIVERS SERVICE IMPROVEMENT ACT OF 2017
S. 591 would expand eligibility for VA's Program of
Comprehensive Assistance for Family Caregivers, expand benefits
available to participants under such program, enhance special
compensation for certain members of the uniformed services who
require assistance, and make other amendments to increase the
provision of benefits.
The Caregivers and Veterans Omnibus Health Services Act of
2010, Public Law 111-163, signed into law on May 5, 2010,
provided expanded support and benefits for caregivers of
eligible and covered Veterans. While the law authorized certain
support services for caregivers of covered Veterans of all
eras, other benefits were authorized only for qualified family
caregivers of eligible Veterans who incurred or aggravated a
serious injury in the line of duty on or after September 11,
2001. These new benefits for approved family caregivers,
provided under the Program of Comprehensive Assistance for
Family Caregivers, include a monthly stipend paid directly to
designated primary family caregivers and medical care under
CHAMPVA for designated primary family caregivers who are not
eligible for TRICARE and not entitled to care or services under
a health-plan contract.
Section 2 of S. 591, the Military and Veteran Caregiver
Services Improvement Act of 2017, would remove ``on or after
September 11, 2001'' from the statutory eligibility criteria
for the Program of Comprehensive Assistance for Family
Caregivers, and thereby expand eligibility under the program to
Veterans of all eras who otherwise meet the applicable
eligibility criteria. Family caregivers could not receive
assistance under this expanded eligibility until FYs 2018,
2020, or 2022 depending on the monthly stipend tier for which
their eligible Veteran qualifies. Section 2 would also add ``or
illness'' to the statutory eligibility criteria, and thereby
expand eligibility to include those Veterans who require a
caregiver because of an illness incurred or aggravated in the
line of duty. In addition, the bill would expand the bases upon
which a Veteran could be deemed to be in need of personal care
services, to include ``a need for regular or extensive
instruction or supervision without which the ability of the
Veteran to function in daily life would be seriously
impaired.''
This section would also expand the assistance available to
primary family caregivers under the Program of Comprehensive
Assistance for Family Caregivers to include child care
services, financial planning and legal services ``relating to
the needs of injured and ill Veterans and their caregivers,''
and respite care that includes peer-oriented group activities.
The bill would ensure that in certain circumstances VA accounts
for the family caregiver's assessment and other specified
factors in determining the primary family caregiver's monthly
stipend amount. In addition, the bill would require VA to
periodically evaluate the needs of the eligible Veteran and the
skills of the family caregiver to determine if additional
instruction, preparation, training, or technical support is
needed, and it would require certain evaluation be done in
collaboration with the Veteran's primary care team to the
maximum extent practicable.
Section 2 would also authorize VA, in providing assistance
under the Program of Comprehensive Assistance for Family
Caregivers, to ``enter into contracts, provider agreements, and
memoranda of understanding with Federal agencies, states, and
private, nonprofit, and other entities'' in certain
circumstances. It would expand the definition of family member
to include a non-family member who does not provide care to the
Veteran on a professional basis, and it would amend the
definition of ``personal care services.'' The bill would also
end the Program of General Caregiver Support Services on
October 1, 2022, but would ensure that all of its activities
are carried out under the Program of Comprehensive Assistance
for Family Caregivers. Finally, the bill would amend the annual
reporting requirements for the Program of Comprehensive
Assistance for Family Caregivers.
In September 2013, VA sent a report to the Committees on
Veterans' Affairs of the Senate and House of Representatives
(as required by Section 101(d) of Public Law 111-163) on the
feasibility and advisability of expanding the Program of
Comprehensive Assistance for Family Caregivers to family
caregivers of Veterans who incurred or aggravated a serious
injury in the line of duty before September 11, 2001. In that
report, VA noted that expanding the Program of Comprehensive
Assistance for Family Caregivers would allow equitable access
to seriously injured Veterans from all eras (who otherwise meet
the program's eligibility criteria) and their approved family
caregivers.
In the report, however, VA noted difficulties with making
reliable projections of the cost effect of opening the Program
of Comprehensive Assistance for Family Caregivers to eligible
Veterans of all eras, but estimated a population range of
32,000 to 88,000 additional Veterans in the first year
(estimated for FY 2014), at a cost of $1.8 billion to $3.8
billion in the first year (estimated for FY 2014). After VA
provided this report to Congress, the RAND Corporation
published a report titled, ``Hidden Heroes: America's Military
Caregivers,'' which estimates a significantly larger eligible
population (1.5 million) that may be eligible if the program
were expanded to caregivers of pre-9/11 Veterans and those
qualifying due to illness. VA's estimates in its 2013 report
did not account for expansion to eligible Veterans with an
illness incurred or aggravated in the line of duty, other
Veterans who would become eligible for the program based on the
amendments in section 2, or the additional assistance that
would become available to primary family caregivers under the
bill. This estimate also did not factor in a phased
implementation of stipend expansion, as contemplated by the
bill.
VA cannot responsibly provide a position in support of
expanding the Program of Comprehensive Assistance for Family
Caregivers without a realistic consideration of the resources
necessary to carry out such an expansion, including an analysis
of the future resources that must be available to fund other
core direct-to-Veteran health care services. This is especially
true as VA presses to strengthen mental health services and
ensure the fullest possible access to care across the system.
We wish to make it very clear that VA believes an expansion
of those benefits that are currently limited by era of service
would result in equitable access to the Program of
Comprehensive Assistance for Family Caregivers for long-
deserving caregivers of those who have sacrificed greatly for
our Nation. However, VA cannot endorse this measure before
further engaging with Congress on these fiscal constraints,
within the context of all of VA health care programs.
Additionally, before expanding eligibility under the
Program, we believe it prudent for VA to ensure that the
current eligibility criteria are applied in a consistent manner
across the program. For example, the National Caregiver Support
Program is undergoing an internal review to evaluate
consistency in revocations and reductions from the Program and
standardize communication with Veterans and Caregivers. On
April 17, 2017, VA suspended certain VA-initiated revocations
in order to carry out this review.
VA welcomes further discussion of these issues with the
Committee.
Section 3 of this bill proposes to add a new section 3319A
to title 38 to authorize individuals who are eligible for and
participating in a program of comprehensive assistance for
family caregivers under 38 U.S.C. Sec. 1720G(a) the opportunity
to transfer their unused Post-9/11 GI Bill education benefits
to their dependents. Veterans may complete the transfer of
entitlement any time during the 15-year period beginning on the
date of their last discharge or release from active duty. There
is no length of service requirement, and the monthly rate of
educational assistance would be the same rate payable to the
individual making the transfer. The Secretary would be
authorized to prescribe regulations to carry out this section.
We note that the Survivors' and Dependents' Educational
Assistance (DEA) program, or chapter 35, currently offers
education and training benefits to eligible dependents of
members of the Armed Forces and Veterans who have a service-
connected disability rated as permanently and totally
disabling, including individuals who are eligible for a program
of comprehensive assistance for family caregivers. Assistance
includes up to 45 months of full-time benefits.
VA supports the intent of section 3 to take care of
caregivers; however, VA cannot support this section as written.
The transfer of entitlement provisions of the Post-9/11 GI Bill
were established as a recruitment and retention tool for the
uniformed services. As such, the Department of Defense (DOD)
determines eligibility for transfer of entitlement. If enacted,
the proposed legislation would require VA to develop procedures
to receive requests to transfer entitlement for certain
individuals, determine eligibility, and award benefits for the
transfer of entitlement program. However, VA notes that
Congress would need to identify appropriate offsets for the
cost of this legislation
Additionally, under the proposed section 3319A, dependents
would receive the same rate of payment as otherwise payable to
the individual making the transfer. This is different than the
rate payable for a dependent child using transferred
entitlement under section 3319. Currently, a dependent child is
awarded benefits as if the individual making the transfer were
not on active duty. As such, a child is entitled to the monthly
housing allowance stipend even though the individual
transferring benefits is still on active duty. Under the
proposed legislation, a child would not be eligible for the
housing allowance while the individual described in 38 U.S.C.
Sec. 1720G(a)(2) is on active duty. This change would impact
the Long-Term Solution for processing Post-9/11 GI Bill claims,
as VA would have to make system modifications in order to apply
a blended set of rules for claims involving transferred
education benefits.
Section 4(a) would amend 37 U.S.C. 439, providing for
special compensation for members of the uniformed services with
catastrophic injuries or illnesses requiring assistance in
everyday living, by amending the definition of covered members
to include those Servicemembers who have a serious injury or
illness that was incurred or aggravated in the line of duty and
are in need of personal care services as a result of such
injury or illness. Section 4(b) would further amend section 439
by requiring VA to provide family caregivers of a Servicemember
in receipt of monthly special compensation the assistance
available to family caregivers of eligible Veterans under 38
U.S.C. Sec. 1720G(a)(3)(A), other than the monthly caregiver
stipend. VA would provide assistance under this subsection in
accordance with a memorandum of understanding (MOU) between VA
and DOD, and an MOU between VA and the Secretary of Homeland
Security. VA would be required to ensure that a family
caregiver in receipt of assistance under this subsection is
able to transition seamlessly to the receipt of assistance
under 38 U.S.C. Sec. 1720G. Section 4(c) would require DOD, in
collaboration with VA, to ensure that members of the uniformed
services in receipt of monthly special compensation are aware
of the eligibility of such members for family caregiver
assistance. Section 4(d) would define the term ``serious injury
or illness,'' which would replace the term ``catastrophic
injury or illness,'' to mean an injury, disorder, or illness
that (1) renders the afflicted person unable to carry out one
or more activities of daily living; (2) renders the afflicted
person in need of supervision or protection due to the
manifestation by such person of symptoms or residuals of
neurological or other impairment or injury; (3) renders the
afflicted person in need of regular or extensive instruction or
supervision in completing two or more instrumental activities
of daily living; or (4) otherwise impairs the afflicted person
in such manner as the Secretary of Defense or Homeland Security
prescribes.
Regarding section 4 of the bill, VA defers to DOD and the
Department of Homeland Security regarding sections 4(a), 4(c),
and 4(d). VA does not support section 4(b) because DOD already
provides many of the services and supports available under VA's
Program of Comprehensive Assistance for Family Caregivers
including health care coverage, mental health services, and
respite care. Requiring VA to provide services under its
program would result in a duplication of efforts.
Section 5 would authorize the Office of Personnel
Management (OPM) to promulgate regulations under which a
covered employee, which would include a caregiver defined in 38
U.S.C. Sec. 1720G or a caregiver of an individual receiving
compensation under 37 U.S.C. Sec. 439, to use a flexible
schedule or compressed schedule or to telework. VA defers to
OPM on this section.
Section 6 would amend the Public Health Service Act (42
U.S.C. Sec. 300ii), which governs lifespan respite care, to
amend the definition of ``adult with a special need'' to
include a Veteran participating in the family caregiver program
under 38 U.S.C. Sec. 1720G(a). It would also amend the
definition of ``family caregiver'' to include family caregivers
under 38 U.S.C. Sec. 1720G. Furthermore, in awarding grants or
cooperative agreements to eligible state agencies to furnish
lifespan respite care, HHS would be required to work in
cooperation with the interagency working group on policies
relating to caregivers of Veterans established under section 7
of this bill. Section 6 would also authorize appropriations of
$15 million for FYs 2017 through 2022 for these grants. VA
defers to HHS on this section.
Section 7 would establish an interagency working group on
policies relating to caregivers of Veterans and Servicemembers.
The working group would be composed of a chairperson selected
by the President, and representatives from VA, DOD, HHS
(including the Centers for Medicare & Medicaid Service), and
the Department of Labor. The working group would be authorized
to consult with other advisors as well. The working group's
duties would include regularly reviewing policies relating to
caregivers of Veterans and Servicemembers, coordinating and
overseeing the implementation of policies relating to these
caregivers, evaluating the effectiveness of such policies,
developing standards of care for caregiver and respite
services, and others. Not later than December 31, 2017, and
annually thereafter, the working group would be required to
submit to Congress a report on policies and services relating
to caregivers of Veterans and Servicemembers.
VA generally supports a working group that would provide a
forum for analyzing and evaluating different issues that family
caregivers of Veterans and Servicemembers face. Such a working
group would be ideally suited to considering in depth the types
of issues other provisions of this bill are intended to address
and would also be able to evaluate emerging issues.
The Department of Justice advises, however, the bill's
method for selecting members of the working group raises
Appointment Clause concerns, which DOJ will convey in greater
detail under separate cover.
We also note several technical concerns with the
legislation in terms of the creation of the working group, its
role, the potential applicability of the Federal Advisory
Committee Act to such a group, and which agency (if any) would
be responsible for initiating, managing, and funding the
working group. We would be happy to discuss these issues with
you upon your request.
Section 8(a) would require VA to conduct a longitudinal
study on Servicemembers who began their service after September
11, 2001. VA would be required to award a grant to or enter
into a contract with an appropriate entity unaffiliated with VA
to conduct the study. Within 1 year of the date of the
enactment of the Act, VA would be required to submit to the
Committees on Veterans' Affairs a plan for the conduct of the
study. Not later than October 1, 2021, and not less frequently
than once every 4 years thereafter, VA would be required to
submit to the Committees on Veterans' Affairs a report on the
results of the study. Section 8(b) would require VA to provide
for the conduct of a comprehensive study on Veterans who have
incurred a serious injury or illness and individuals who are
acting as caregivers for Veterans. VA would be required to
award a grant to or enter into a contract with an appropriate
entity unaffiliated with VA to conduct the study. The study
would be required to include the health of the Veteran and the
impact of the caregiver on the health of the Veteran, the
employment status of the Veteran and the impact of the
caregiver on that status, the financial status and needs of the
Veteran, the use by the Veteran of VA benefits, and any other
information VA considers appropriate. No later than 2 years
after the date of the enactment of this Act, VA would be
required to submit to the Committees on Veterans' Affairs a
report on the results of this study.
VA does not support section 8, as it would duplicate
research in several ongoing or in-development studies. DOD and
VA have a collaboration on the Millennium Cohort Study, a
longitudinal cohort study that has and will continue to produce
findings on health issues of multiple eras of military service.
The Million Veterans Program creates a repository of clinical
and genetic information on Veterans, including post-9/11
Veterans, which will provide data for targeted studies on
health for years to come. VA's Cooperative Studies Program is
developing a study on the respiratory health of Gulf War and
post-9/11 Veterans. Finally, a study of the life transitions of
military Servicemembers who served in Iraq or Afghanistan is
funded and in development.
VA estimates section 8 would cost $4.3 million in FY 2018,
$17.5 million over 5 years, and $34 million over 10 years, with
additional close out expenses of $3.3 million in FY 2028 for a
total cost of $37.3 million.
DRAFT--VETERAN PARTNERS' EFFORTS TO ENHANCE REINTEGRATION (PEER) ACT
The draft bill would require the Secretary to phase in and
conduct a program whereby peer specialists would be included in
patient aligned care teams at VAMCs to promote the use and
integration of mental health services in a primary care
setting. Not later than 180 days after the date of enactment,
this program would have to be established at not fewer than 10
VAMCs. By not later than 2 years from the date of enactment, it
would have to be in place at not fewer than 25 VAMCs. Under the
bill, the Secretary would be directed to consider specified
factors when selecting sites for this program, but, not fewer
than five would have to be established at VA designated
Polytrauma Centers, and not fewer than ten would have to be
established at other VAMCs. The draft bill would also require
that all peer specialist programs established under this
mandate: (1) ensure that the needs of female Veterans are
considered and addressed; and (2) include female peer
specialists. Finally, this measure would establish initial,
periodic, and final Congressional reporting requirements, as
detailed in the bill.
VA has no objection to the bill, but notes that it is not
necessary because VA already has the authority to execute this
program. However, we would require additional funding to
implement it. We also note that a few technical changes are
needed for clarity. This legislation, if enacted, would
complement VA's ongoing pilot program (commenced in 2014)
whereby peer support through peer specialists has been extended
beyond traditional mental health sites of care to include
Veterans receiving mental health care in primary care settings.
Under the pilot program, trained peer specialists work with VA
primary care teams to, in general terms, help improve the
health and well-being of other Veterans being treated in VA
primary care settings. All 25 sites now have assigned one peer
specialist to work in Primary Care at least 10 hours per week.
The first cohort of eight sites began seeing Veterans in
primary care in January 2016, the second cohort of eight began
in August 2016, and the final nine sites began April 1, 2017.
To date, the peers in this program have provided services to
more than 3,000 Veterans. The response from Veterans, peers,
and primary care clinicians has been overwhelmingly positive.
Sites made a 1- year commitment to participate in the project,
and VA will have a formal program evaluation based on clinical
and other outcomes in 2018. It is likely that some of the
existing sites will not be able to continue the pilot program
after FY 2017 without additional funding.
The bill specifies program participation of female peer
specialists. I am pleased to report that women peer specialists
are already well represented, with 16.2 percent of the national
peer specialist workforce being women. While at first glance
16.2 percent may seem a low rate, please bear in mind that this
figure is higher than the percentage of Veterans seeking
services through VA who are women. We do recognize, however,
that the current number of women Veteran peer specialists in
the pilot is unevenly distributed across the country, with some
VAMCs having greater difficulty than others in attracting
qualified applicants.
Also, it is unclear if the peers will address substance use
disorders under the umbrella of their mental health duties.
Given the comorbidity of these issues, the need for integration
of substance use disorder identification and care, the need for
overdose prevention and links as needed to Medication Assisted
Treatment for opioid use disorders, and the need to increase
the numbers of Veterans achieving long-term recovery, we
recommend that this be clarified and, if possible, included.
We estimate this bill would cost $4.94 million in FY 2018,
$25.99 million over 5 years, and $55.48 million over 10 years.
DRAFT--SERVING OUR RURAL VETERANS ACT OF 2017
The draft bill would amend 38 U.S.C. Sec. 7406(c) to
authorize training and supervision of residents at facilities
operated by an Indian tribe, a tribal organization, or the
Indian Health Service, Federally-qualified health centers, and
community health centers. It would also direct VA, in
consultation with the Director of the Indian Health Service, to
carry out a pilot program to establish graduate medical
education residency training programs at such facilities and to
affiliate with established programs. VA would be required to
carry out the pilot program at not more than four covered
facilities and would carry out the pilot program for a period
of 8 years beginning on the date that is 180 days after the
date of enactment. VA would be required to reimburse certain
costs associated with the program and to enter into agreements
with individuals participating in the pilot program under which
they would agree to serve a period of 1 year at a covered
facility (including a VA facility) service for each year in
which the individual participates in the pilot program. The
bill would provide terms related to breach of the agreement,
loan repayment, and concurrent service. VA would be required to
submit a report to the Committees on Veterans' Affairs of the
House of Representatives and the Senate not later than 3 years
before the termination of the pilot program on the feasibility
and advisability of expanding the pilot program to additional
locations and making the pilot program or any part of it
permanent. The draft bill would authorize to be appropriated to
VA $20 million per year to carry out the pilot program and
would also authorize appropriations for the Secretary of HHS,
acting through the Director of the Indian Health Service, and
to VA such sums as may be necessary to cover loan repayments
under each agency's respective loan repayment programs.
VA supports the draft bill in principle. VA strongly
supports the imperative to build Graduate Medical Education
capacity in rural and underserved areas with the strategic
intent to address a geographically inequitable distribution of
the Nation's physician and clinical workforce.
While we appreciate the purpose of this bill, it is likely
that a relatively small proportion of the patients seen by
residents in such programs would be Veterans, yet VA would
incur much of the burden for program initiation and maintenance
including resident salaries, faculty time and development,
curriculum development, and recruitment efforts.
Under the draft bill, a medical resident who participates
in the pilot program would be eligible for participation in the
Indian Health Service Loan Repayment Program under section 108
of the Indian Health Care Improvement Act (section 1616a of
title 25, U. S. C.) and the VA Education Debt Reduction
Program. The draft bill also would include a period of
obligated service (1 year of service at VA for each year of
participation in the program). VA supports such a loan
repayment and obligated service scheme, but recommends
requiring 2 years of service for each year of program
participation. Moreover, because residents typically receive a
salary and are not obligated, post-residency, to perform
services as a result of participating in a residency program,
VA requests the authority to concurrently provide educational
loan repayment to residents in the program(s) as a tool to
recruit highly qualified residents.
VA fundamentally believes that supporting the practice of
rural health care in the United States is crucial to fulfilling
its mission to provide the highest quality care for Veterans
and that we must include within our broad health professions
education portfolio a focus on rural health in order to meet
our statutory mission to provide medical education for VA and
for the Nation. VA endorses educating all physicians regarding
the unique health needs of Veterans and providing clinical
training opportunities in rural health care delivery systems.
VA estimates the cost of implementation at four sites would
be $20.3 million in FY 2018, $90.6 million over 5 years, and
$201.8 million over 10 years.
Mr. Chairman and Members of the Committee, this concludes
my statement. I would be happy to answer any questions you may
have.
------
STATEMENT OF BALIGH R. YEHIA, M.D., DEPUTY UNDER SECRETARY FOR HEALTH
FOR COMMUNITY CARE, VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF
VETERANS AFFAIRS
Good morning, Chairman Isakson, Ranking Member Tester, and
Members of the Committee. Thank you for inviting us here today
to present our views on several bills that would affect the
Department of Veterans Affairs' (VA or Department) programs and
services. Joining me today is Dr. Tom Lynch, Assistant Deputy
Under Secretary for Health Clinical Operations, Veterans Health
Administration (VHA); Brad Flohr, Senior Advisor for
Compensation Services, Veterans Benefits Administration; and
Carin Otero, Assistant Deputy Assistant Secretary for Human
Resources Policy and Planning, Human Resources and
Administration.
This written statement includes VA's views on eleven
significant bills on important topics. Because of the timing of
receipt of two of the bills, we are not able to provide formal
views in this statement on S. 1279, the Veterans Health
Administration Reform Act of 2017 or the draft bill, ``The
Department of Veterans Affairs Quality Employment Act of
2017.'' We also will follow up with the Committee on one
section (section 10) of the Veterans Choice Act of 2017. We
look forward to providing views at a later time and discussing
these bills with you today.
S. 115--VETERANS TRANSPLANT COVERAGE ACT
S. 115 would add section 1788 to Title 38, authorizing the
Secretary of Veterans Affairs (Secretary) to provide for an
operation on a live donor to carry out a transplant procedure
for an eligible Veteran, notwithstanding that the live donor
may not be eligible for VA health care. VA would be required to
provide to a live donor any care or services before and after
conducting the transplant procedure that may be required in
connection with the transplant.
VA supports S. 115, contingent on the provision of
additional resources to support implementation, although we
recommend some clarifications in the bill language. We believe
it would be appropriate to limit the duty and responsibility to
furnish follow-on care and treatment of a living donor to 2
years after the procedure is performed by a VA facility. This
would be consistent with the recommendations of the United
Network for Organ Sharing and the Organ Procurement and
Transplant Network. We further recommend that the duty to
provide follow-on care and treatment should be limited to that
which is ``directly related to'' the living donor procedure
(rather than what ``may be required in connection with such
procedure,'' as the bill would provide).
There are other potential issues related to organ
transplantation that the bill does not address that we would be
pleased to discuss with the Committee in its contemplation of
this proposal.
We estimate the bill as written would cost $1.8 million in
Fiscal Year (FY) 2018, $9.7 million over 5 years, and $21.5
million over 10 years.
S. 1153--VETERANS ACQUIRING COMMUNITY CARE EXPECT SAFE SERVICES
(ACCESS) ACT OF 2017
S. 1153 would require the Secretary of Veterans Affairs to
deny or revoke eligibility of certain health care providers to
provide non-VA health care services to Veterans. The bill
would, in general, require that the Secretary deny or revoke
the eligibility of a health care provider to provide non-
Department health care services if the Secretary determines
that: (1) the provider was removed from employment at VA due to
conduct that violated a policy relating to the safe and
appropriate delivery of health care; (2) the provider violated
the requirements of a medical license; (3) the provider had a
Department credential revoked that would impact that provider's
ability to provide safe and appropriate health care; or, (4)
the provider violated a law for which a term of imprisonment of
more than 1 year may be imposed. The bill would permit, but not
require, the denial, revocation, or suspension of the
eligibility of a health care provider to furnish non-Department
health care when the Secretary has a reasonable belief that
such action is necessary to immediately protect the health,
safety, or welfare of Veterans and: (1) the provider is under
investigation by the medical licensing board of a State in
which the provider is licensed or practices; (2) the provider
has entered into a settlement agreement for a disciplinary
charge related to the practice of medicine; or, (3) the
Secretary otherwise determines that such action is appropriate
under the circumstances. The bill would require that the
Secretary suspend the eligibility of a health care provider to
provide non-Department care if that provider is suspended from
serving as a health care provider of the Department. The bill
also would require that the Secretary review, within 1 year of
enactment, each non-Department health care provider to identify
whether he or she was an employee of the Department to
determine if the provider meets any of the criteria for denial,
revocation, or suspension of eligibility. Finally, the bill
would require the Comptroller General to submit a report to
Congress within 2 years of enactment on the implementation of
these authorities and its effects.
VA supports the proposed legislation in principle and would
appreciate the opportunity to work with Congress to develop a
proposal that builds upon similar requirements already in place
without creating the unnecessary administrative burdens we
believe the bill would produce, as these burdens could
negatively impact Veterans' access to quality care. Currently,
VA procures most community care using Third Party
Administrators (TPA), under Patient Centered Community Care
(PC3)/Choice contracts, which include the development and
maintenance of an adequate provider network of high quality,
credentialed/certified health care providers. VA monitors
adherence by performing quality checks through the use of a
Quality Assurance Plan (QASP). As part of the QASP, VA utilizes
a ``three lines of defense'' model to oversee the credentialing
and certification process of network health care providers.
These lines of defense involve both VA and the TPA performing
ongoing reviews to ensure the quality of the providers in the
network. Additionally, VA requires the contractor to report to
VA, not more than 15 days after being notified, of the loss of
or other adverse impact to a network provider's certification,
credentialing, privileging, or licensing. Future acquisitions
will carry similar criteria as they pertain to review of
provider licensure and credentialing, as VA remains committed
to developing contracts for high performing networks.
Because of the measures already in place to ensure that VA
only utilizes the highest quality providers in the community,
VA is concerned that the administrative requirements of this
legislation as written would have the potential to adversely
impact Veteran access to community care as well as limit
current and future contractors' ability to timely recruit and
retain qualified providers within their networks.
VA also has concerns relating to due process protections
under the bill. To the extent VA relies on any fact that had
not been established through a complete and fair process
satisfying the requirements of due process (e.g., a criminal
conviction, or a full investigation and determination by a
State licensing board), the Agency's decision should be
appealable. VA does not have an existing process that could
accommodate such appeals. Affected providers must be given
notice and an opportunity to be heard to contest such
determinations or beliefs in order to satisfy due process
requirements, but it is unclear how VA would provide for this.
VA is unable to provide a cost estimate for this proposal
as currently written because it is unclear what additional
administrative requirements would be needed to ensure
appropriate review and protections are in place.
S. 1325--BETTER WORKFORCE FOR VETERANS ACT OF 2017
The draft bill, ``Better Workforce for Veterans Act of
2017,'' contains a number of provisions intended to improve the
authorities of the Secretary to hire, recruit, and train
employees of the Department.
Section 101(a) would create a new section 718 that would
authorize the Secretary to recruit and appoint qualified recent
graduates and post-secondary students to competitive service
positions within the Department, notwithstanding certain
provisions of Title 5. The Secretary would only be authorized
to appoint no more than a number equal to 15 percent of the
number of hires made into professional and administrative
occupations at the GS-11 level or below (or equivalent) during
the previous fiscal year. The Secretary would be required to
develop regulations governing this authority. To the extent
practicable, the Secretary would be required to publicly
advertise positions available under this section within certain
constraints.
VA supports the concept of this provision, but also would
like to note that the Administration authored a similar
proposal that would be applicable to all agencies, and
transmitted it for consideration in the FY 2018 National
Defense Authorization Act (FY 2018 NDAA). This would provide
greater flexibility to hire students and recent college
graduates, providing an immediate opportunity for new employees
to begin their careers with VA. The Administration would prefer
a Government-wide solution that would provide a significant
recruitment benefit if all agencies were able to utilize it.
Section 101(b) would create a new section 719 that would
require the Secretary to prescribe regulations to allow for
excepted service appointments of certain students and recent
graduates leading to conversion to career or career conditional
employment.
VA defers to OPM on implementation of this provision as an
important element to implementing the program authorized by
section 101(a) for certain students and interns. OPM would be
best suited to provide any necessary technical drafting
assistance to align these authorities with OPM's current
Government-wide Pathways Program.
Section 102 would amend section 3304(a)(3)(B) of Title 5 to
permit the Secretary to appoint directly for positions for
which there is a severe shortage of highly qualified
candidates. OPM would have the authority to determine what
positions would qualify, as well as having the ability to
delegate the authority to make those determinations.
VA supports this provision as this would provide greater
flexibility to directly reach applicants when we have a severe
shortage of highly qualified candidates. This would help the
Department address some of its most critical vacancies.
Section 103 would create a new section 712 to authorize the
Secretary to appoint a former Federal employee to a high-demand
position within the Department for which the former Federal
employee is highly qualified without regard to provisions
concerning competitive appointments. The former Federal
employee could be appointed to a position at a higher grade or
with more promotion potential than the position the employee
previously held. Within 18 months of enactment, the Inspector
General of the Department would be required to conduct an audit
of the use of this authority by the Secretary and report to
Congress on the results of that audit.
VA defers to OPM on this provision. Currently, we could
hire someone non-competitively to a position at the same level
they previously held, while this provision would allow VA to
hire someone to a higher level than they previously held.
Therefore, implementation would need to be measured, with
appropriate controls in place to prevent misuse.
Section 104 would create a new section 720 to require the
Secretary to develop and implement a resume-based application
method for applications for appointment to senior executive
positions within VA. The application would have to be, to the
extent practicable, comparable to the resume-based application
method for the Senior Executive Service (SES) developed by the
Office of Personnel Management (OPM), and would have to be used
for initial applications for a position as a senior executive
to the extent such use will be more efficient and effective and
less burdensome for all participants. The Secretary would be
authorized to make an initial career appointment of an
individual to a position as a senior executive if a review
board convened by VA certifies the executive and managerial
qualifications of the individual.
At this time, VA does not support this provision because we
do not believe it is necessary. Resume-based application is
allowed under current rules, and VA would like to maintain
flexibility in hiring and assessment. VA currently uses a
resume-based system for executive recruitment for its medical
center Director positions, and with the recently enacted
Department of Veterans Affairs Accountability and Whistleblower
Protection Act of 2017 (Public Law 115-41), signed June 23,
2017, VA now has direct hiring authority for these and VISN
Director positions. We continuously evaluate our hiring
methods, timeframes, and outcomes to identify opportunities for
improvement, and we would be happy to share our findings with
the Committee.
Section 105 would establish a new section 721 that would
require the Secretary to establish and periodically review a
single database that lists each vacant position in VA that the
Secretary determines is critical to VA's mission, difficult to
fill, or both. If the Secretary determines that an applicant
for a position listed in the database is qualified for such
position, but the Secretary does not select such applicant, the
Secretary, at the election of the applicant, would be required
to consider the applicant for other, similar vacant positions
listed in the database. If the Secretary did not fill a vacant
position listed in the database after an appropriate time (as
determined by the Secretary), the Secretary would be required
to ensure that applicants who were not selected for other
positions but who meet the qualification requirements are
considered. The Secretary would also be required to use the
database to assist in filling such positions. Within 1 year of
enactment, the Secretary would be required to submit a report
to Congress on the use and efficacy of the database established
under this section.
We support the concept of identifying and maintaining a
database of vacancies, but do not support this particular
provision. VA completed the implementation of a commercial
software product as the core foundation to our new enterprise
automated human resources system. We will implement an
enhancement in FY 2018 to manage positions, which will provide
real-time vacancy information. With the systems we currently
have in place and in development, we believe we can meet the
intent of this provision without legislation, and in a way that
is less administratively burdensome.
Section 106 would create a new section 722 that would
require the Secretary to measure and collect information on
indicators of hiring effectiveness concerning certain
identified factors related to recruiting and hiring candidates,
as well as the satisfaction of employees, newly hired
employees, and applicants. To the extent practicable, and in a
manner protecting personally identifiable information, the
Secretary would be required to collect and report data
disaggregated by facility and VISN to ensure the data is
collected from human resources offices throughout VA. The
Secretary would be required to submit an annual report to
Congress on the information collected, and to make such
information publicly available.
As written, we do not support this provision. We are
concerned the vagueness of the language could result in
application to virtually every aspect of the recruitment
process. The terminology in this provision includes subjective
terms, and we believe some provisions may be inconsistent
internally. In addition, these provisions could be inconsistent
with other agencies' recruitment and hiring information. We
have a number of technical comments and recommendations and
would be glad to share those with the Committee. We also would
request that the Committee solicit OPM for technical drafting
assistance on this provision.
Section 107 would create a new section 723 requiring the
Secretary to develop and carry out a standardized, anonymous,
voluntary exit survey for career and non-career employees who
voluntarily separate from VA. The survey would have to ask
questions regarding the reasons for leaving, any efforts made
to retain the individual, the extent of job satisfaction and
engagement, the intent of the employee to remain in or leave
Federal employment, and other matters considered appropriate by
the Secretary. The Secretary would be required to share the
results of the survey with the directors and managers VA
facilities and VISNs, and the Secretary would be required to
report annually on the aggregate results of the exit survey.
We do not support this provision because we believe it is
unnecessary, given that we already use exit surveys that
capture almost all of the content this legislation would
require.
Section 108 would amend section 2108(1) of Title 5
concerning Veteran preference so that any Veteran who served a
total of more than 180 days would qualify, rather than only
those who served more than 180 consecutive days.
We note that this provision would amend title 5 and apply
to the entire Federal government. As a result, we defer to OPM
on this provision.
Section 109 would amend section 705(a) of the Veterans
Access, Choice, and Accountability Act of 2014 to clarify that
recruitment, relocation, or retention incentives are not
subject to the limitations on awards and bonuses available in
the Department.
VA supports this provision. Currently, the limitations on
awards and bonuses include recruitment, retention, and
relocation incentives, which have severely limited the
Department's ability to offer incentives to hire and retain
critical positions. Under these limitations, the Department has
attempted to reserve the bulk of the funds that are available
to provide incentives to positions, particularly medical
professionals with specialized skills and expertise that would
be difficult or impossible to replace. This has resulted in an
inequitable treatment among employees, as there are fewer
resources available for those otherwise deserving and equally
dedicated employees.
If this authority were enacted, VA would reallocate funds
already appropriated for recruitment and retention of highly
qualified employees.
Section 110 would amend section 7309 of Title 38 to remove
the requirements that the Chief Officer of VA's Readjustment
Counseling Service (RCS) must have at least 3 years of
experience providing direct counseling services or outreach
services through RCS, as well as 3 years of experience
administrating direct counseling services or outreach services
through RCS.
VA supports this provision. This would provide greater
flexibility to appoint the Chief Officer of RCS, which oversees
VA's Vet Centers, a critical component to providing Veterans
and Servicemembers readjustment counseling and other services.
There would be no costs associated with this provision.
Section 111 would require, within 120 days of the date of
the enactment of this Act, the Secretary to submit a report to
Congress on vacancies within the Veterans Health
Administration. This report would have to include vacancies of
personnel appointed under section 7401 of title 38, vacancies
of human resource specialists in VHA, a description of any
impediments to filling certain vacancies, and an update on the
implementation of several plans and reports.
We do not believe section 111 is necessary, but we do not
oppose this requirement. Until the system enhancement
previously mentioned is implemented in FY 2018, collecting this
information is a manual and intensive effort. As a result, we
are concerned that the 120 day deadline would be difficult to
meet. We believe that we would be in a better position to
gather this information within the next year.
Section 201 would create a new section 724 providing that
for any reduction in force by VA, competing employees would be
released with due effect to the following in order of priority:
tenure of employment, military preference, efficiency or
performance ratings, and length of service.
We do not oppose section 201 because this would only change
the order of consideration for how reductions in force would
occur. However, we would defer to OPM, to ensure that reduction
in force procedures remain consistent across the Government. We
note that for hybrid title 38 positions, we think it would be
appropriate to also consider the level and type of licensure,
as well as the scope of practice, in making such
determinations.
Section 202 would create a new section 725 authorizing the
Secretary to arrange, with the agreement of a private-sector
organization, for the temporary assignment of VA employees to
such organization to occupy a position in that organization and
for the private sector employee who held that position to
temporarily occupy the position of the VA employee. In essence,
these employees would be trading positions for a temporary
period. The VA employee would return to work for the
Department, and if either employee failed to carry out the
agreement, the employee would be liable to the United States
for payment of all expenses of the assignment, with certain
exceptions; such liability would be a debt that could be waived
if the Secretary determined collecting it would be against
equity and good conscience and not in the best interests of the
United States. The VA employee would be prohibited from using
pre-decisional, draft deliberative, or other information for
the benefit or advantage of the private sector organization.
Assignments would be for periods between 3 months and 4 years.
VA employees assigned to the private sector organization would
be considered, during the period of assignment to be on detail
to a regular work assignment in the Department for all
purposes. The private sector employee assigned to VA employment
would generally not be considered a Federal employee with
certain exceptions and would have other constraints imposed
upon the scope of that employee's work with the Department. The
private sector organization would be prohibited from charging
VA, as direct or indirect costs under a Federal contract, for
the pay or benefits paid by the organization to the employee
assigned to VA. The Secretary would be required to take into
account certain considerations in operating this program.
In theory, VA supports the concept of rotational
assignments for professional development, and notes that the
Administration submitted, in the context of the FY 2018 NDAA, a
similar proposal to provide government-wide authority for
industry exchange programs. We note, however, that the
potential for conflicts of interest in this provision are
significant, notwithstanding the language in the bill
attempting to limit this. There are several areas where this
provision is ambiguous, and we would appreciate the opportunity
to discuss this further with the Committee prior to taking a
position on this section. We would recommend that the Committee
work with the Office of Government Ethics on the appropriate
language to address issues related to conflicts of interest.
Section 203 would amend section 7306 to allow for the
appointment of VISN Directors in addition to medical center
Directors to suit the needs of the Department. It would also
remove the requirement for these Directors to be qualified
doctors of medicine, or doctors or dental surgery or dental
medicine. It would further amend that section to allow the
Secretary to establish qualifications for these Directors and
appoint them under this authority. The Secretary and the
Director would be required to enter into an agreement that
permits employees appointed under this authority to transfer to
SES positions in other Federal agencies and to be deemed career
appointees who are not subject to competition or certification
by a qualifications review board.
Section 207 of the Department of Veterans Affairs
Accountability and Whistleblower Protection Act of 2017 (Public
Law 115-41), signed June 23, 2017, significantly amended VA's
authority to hire directly VISN and medical center Directors.
In this context, we would like the opportunity to discuss this
proposal further with OPM and the Committee to consider the
effects of these proposed changes before taking a position on
this section.
Section 204 would create a new subchapter VII in chapter 74
concerning pay for medical center Directors and VISN Directors.
The new section 7481 would provide that pay for these Directors
would consist of basic pay and market pay, which would be
determined by the Secretary on a case-by-case basis and consist
of pay intended to reflect the needs of the Department with
respect to recruitment and retention of such Directors. The
bill would impose other requirements in terms of determining
market pay under this section. The Secretary would be required,
not less frequently than once every 2 years, to set forth
within defined parameters Department-wide minimum and maximum
amounts for total pay for Directors, and to publish such limits
in the Federal Register. Pay under this section would be
considered pay for all purposes, including retirement benefits.
A decrease in the pay of a Director resulting from an
adjustment in market pay could not be considered an adverse
action, while a decrease resulting from an involuntary
reassignment in connection with a disciplinary action would not
be subject to appeal or judicial review. The OPM Director would
be required to undertake periodic reviews of the Secretary's
determinations and certify to Congress each year whether or not
the market pay is in accordance with the requirements of this
section. If the Director determined the amounts were not in
accordance with the requirements of this section, the Director
would report to Congress on such determination as soon as
practicable after making such determination.
We appreciate the Committee's interest in this regard.
Similar to section 203, we note that given the recent change
(Public Law 115-41) in our appointment authority for VISN and
medical center Directors, we would like to discuss this
proposal further with OPM and the Committee prior to taking a
position on the specific provisions in this section. We
anticipate there would be additional costs to implement this
section.
Section 205 would create a new section 7413 that would
require the Secretary to provide to VHA human resources
professionals training on how best to recruit and retain VHA
employees. The Secretary would provide such training in a
manner considered appropriate considering budget, travel, and
other constraints. The Secretary would be required to ensure
that each VHA human resources professional received such
training as soon as practicable after being hired and annually
thereafter. The Secretary would be required to ensure that a
medical center Director, VISN Director, or senior officer at
Central Office certified that the professional completed such
training. The Secretary would be required to report annually on
the training provided under this authority, including the cost
of such training, and the number of professionals who receive
such training.
We do not support section 205 because VA already has the
authority to conduct such training. VA provides training to
human resources professionals currently, and we are concerned
that the specific requirements in this provision could
constrain our ability to adapt training to emerging needs. We
also have some technical concerns with this provision that we
will share with the Committee.
Section 206 would require the Secretary to include
education and training of marriage and family therapists and
licensed professional mental health counselors in carrying out
the education and training programs conducted under section
7302(a)(1). The Secretary would be required, to the degree
practicable, to ensure that the licensing and credentialing
standards for therapists and counselors participating in this
program are the same as the licensing and credentialing
standards for eligibility of other participants in the program.
Finally, the Secretary would be required to apportion funding
for education and training equally among the professions
included in the program.
In general, we currently have the authority to carry out
this section. VA has already established training programs for
licensed professional mental health counselors and marriage and
family therapists. We are concerned with the potential effect
this could have on the quality of the education and training
standards, and we would appreciate the opportunity to discuss
this further with the Committee. We are also concerned that the
language, particularly in subsection (c) of this provision, is
too prescriptive and could limit VA's flexibility to adjust
training needs and resources to meet operational needs.
Section 207 would require, within 180 days of the date of
enactment of this Act, the Secretary and the Surgeon General to
enter into a memorandum of understanding (MOU) for the
assignment of not fewer than 500 commissioned officers of the
Regular Corps of the Public Health Service to VA. The Secretary
would reimburse the Surgeon General for expenses incurred in
assigning commissioned officers to VA. Within 1 year of
enactment, the Secretary and Surgeon General would each be
required to submit to Congress a report on the MOU and the
commissioned officers assigned under this authority.
We do not support this provision because it is unnecessary.
VA and the Department of Health and Human Services (HHS) signed
an MOU earlier this year to allow for commissioned officers of
the Public Health Service to serve in VA. We would like the
opportunity to discuss this further with the Committee and HHS
to determine what, if any, legislative authority we need in
this area.
Section 208(a) and (b) would require, within 1 year of the
date of enactment of this Act, the Under Secretary for Health
to develop a comprehensive competency assessment tool for VHA
human resources employees to assess the knowledge of such
employees on how employees appointed under section 7401(1) are
treated differently than employees appointed under other
authorities. Within 2 years of the date of enactment of this
Act, and once every 2 years thereafter, the Secretary would
have to submit a certification to Congress as to whether an
assessment of all VHA human resources employees was conducted
and whether such employees used the results of such assessment
to identify and address competency gaps. Within 18 months of
the date of enactment of this Act, the Under Secretary for
Health would be required to evaluate the extent to which these
training strategies are effective at improving the skills and
competencies of VHA human resources employees.
Section 208(c) would require, within 1 year of enactment,
the Under Secretary for Health to establish clear lines of
authority that provide the Assistant Deputy Under Secretary for
Health for Workforce Services the ability to oversee and hold
the heads of the human resources offices of VA medical centers
accountable for implementing initiatives to improve human
resources processes and for ensuring employees undertake the
assessment required under subsection (a). Within 1 year of
enactment of this Act, the Secretary would be required to
clarify the lines of authority and processes for the Under
Secretary for Health and the Assistant Secretary for Human
Resources and Administration with respect to overseeing holding
the VISN and VA medical center Directors accountable for the
consistent application of Federal classification policies.
Section 208(d) would require the Secretary to ensure the
Under Secretary for Health and the Assistant Secretary for
Human Resources and Administration are responsible for
monitoring the status of corrective actions taken at human
resources offices of VA medical centers and that such actions
are implemented.
Section 208(e) would require the Secretary to ensure that
meaningful distinctions are made in performance ratings for VHA
employees.
Section 208(f) would require, within 1 year of enactment of
this Act, the Under Secretary for Health and the Assistant
Secretary for Human Resources and Administration to develop a
plan to implement a modern information technology (IT) system
to support employee performance management processes.
Section 208(g) would require, within 1 year of enactment of
this Act, the Under Secretary for Health to establish clear
lines of authority and accountability for developing,
implementing, and monitoring strategies for improving employee
engagement across VHA. The Under Secretary for Health would be
required to report to Congress on whether VHA should establish
an employee engagement office at the headquarters level with
appropriate oversight of VISN and VA medical center employee
engagement initiatives.
We do not believe this section is necessary. We are
currently implementing the requirements of these provisions
based on the recommendation of a Government Accountability
Office (GAO) report (GAO 17-30). We also have some technical
concerns we believe need to be addressed, and we will be glad
to provide those to the Committee.
Section 208(h) would require, within 1 year of enactment,
the Comptroller General to examine the overlapping functions of
human resource structures within VHA and the Office of the
Assistant Secretary of Human Resources, whether there are
opportunities to centralize offices and tasks that are
duplicative, and whether the use of multiple hiring structures
has had an effect on the speed with which VA hires new
employees. The Comptroller General would report to Congress on
the Comptroller General's findings.
VA defers to the Comptroller General on this provision.
Section 209 would require, within 120 days of enactment of
this Act, the Secretary to report to Congress on the effect the
freeze on the hiring of Federal civilian employees ordered by
the President on January 23, 2017, has had on the ability of VA
to provide care and services to Veterans.
We do not believe this is necessary, and do not support it,
as the hiring freeze was only in effect, at most, for a limited
number of positions not related to patient care or access. We
also do not believe it would be possible to identify to any
meaningful degree any effects that may have occurred as a
result of the hiring freeze.
Section 210 would require, within 180 days of enactment of
this Act, the Secretary to report to Congress on how the
Secretary plans to implement the portions of the plan of the
OPM Director to reduce the size of the Federal workforce
through attrition as it pertains to VA.
We believe this provision is unnecessary. VA is working to
implement an agency reform plan, consistent with the OMB
Director's requirements. We are looking at how we will be
filling administrative positions that become vacant, along with
other potential actions, and will be updating these plans and
assessments in the future. We would be happy to share with the
Committee the plan the Department submits to OMB when it is
available.
Section 211 would require, within 180 days of enactment of
this Act, the Secretary to publish online information on
staffing levels for nurses at each VA medical facility. The
head of each medical facility would be required to update the
information as changes to the staffing level of nurses at the
facility occur. The Secretary would be required to consult with
Centers for Medicare & Medicaid Services in developing the
information required by this section. The Secretary would be
required to submit a report to Congress discussing and
assessing the use by medical center Directors of authorities to
provide nurses pay that reflects market conditions, the
adequacy of training resources for nurse recruiters, the key
recruitment and retention incentives of VHA for nurses, and
other factors.
We do not support this provision for two major reasons.
First, the staffing levels referenced in the bill are not
defined. Second, the actual number of nurses varies on an
almost daily basis given the volatility in terms of staffing.
It would be incredibly cumbersome to maintain this information
and update it in real time. We already report to Congress each
year on efforts to provide nurses greater pay, and this report
would be duplicative of that effort.
Section 212 would require, within 1 year of enactment of
this Act, the Secretary, in consultation with the OPM Director,
to ensure that the job description, position classification,
and grade for each position as a police officer or firefighter
in VA are in accordance with standards for the classification
of such positions prepared by OPM. The Secretary would be
required to develop a staffing model for the positions of
police officers and firefighters within the Department. The VA
Inspector General would be required to conduct an audit of VA's
efforts to recruit and retain police officers and firefighters
and report to the Secretary and Congress on the audit's
findings. Finally, the Secretary would be required to report to
Congress on the use by medical center Directors of special pay
incentives to recruit and retain trained and qualified police
officers and the steps the Secretary plans to take to address
the critical shortage of police officers throughout the
Department.
We have some concerns with this provision. We believe the
reviews required by this section could require a considerable
amount of resources. We would like the opportunity to discuss
this proposal further with the Committee and OPM to determine
what we may be able to do currently to address the Committee's
concerns and interests in this matter.
Section 213 would require, within 1 year of enactment of
this Act, the VA Inspector General to complete a study on how
VHA communicates its directives, policies, and handbooks to the
field, including the compliance with such documents, and the
effectiveness of each VISN in disseminating information to
employees within the Network and Veterans served by the
Network.
The Department defers to the Inspector General on this
provision.
As noted above, VA will be providing follow-up views for
the record on S. 1279, the Veterans Health Administration
Reform Act, the draft Department of Veterans Affairs Quality
Employment Act of 2017, and section 10 of the Veterans Choice
Act of 2017.
S. XXXX--VETERANS CHOICE ACT OF 2017
The draft Veterans Choice Act of 2017 contains a number of
provisions intended to improve VA's community care program.
Community care has helped significantly expand access to care
for Veterans nationally and plays an important role in VA's
effort to build a modern, integrated health care network.
Section 3(a) of the bill would amend section 1703 of title
38 to authorize the Veterans Choice Program. Under this
Program, all enrolled Veterans would be eligible to elect to
receive hospital care, medical services, mental health
services, and certain diagnostic services, outpatient dental
services, and diagnostic services from specified eligible
providers. These services could be provided through
telemedicine, at the election of the Veteran. The Secretary
would be required to enter into consolidated, competitively bid
regional contacts with health care organizations or third party
administrators to establish networks of eligible providers for
the purpose of providing sufficient access to care and
services. The bill would define various responsibilities for
these organizations or administrators, including enrolling
covered Veterans, conducting referrals and authorizations,
customer service, and maintaining an interoperable electronic
health record. These parties would be required to leverage
advanced technology to allow Veterans to make their own
appointments, including online and through smart phone
applications. Veterans who need assistance making their
appointments could receive assistance from the organization or
administrator or the Secretary. The organizations or
administrators would be required to meet capability, capacity,
and access standards established by the Secretary, including
those established pursuant to sections 9 and 10 of this bill.
Providers who currently furnish care or services under another
authority would be offered the opportunity to furnish care and
services through this Program.
Under the Veterans Choice Program, the rates paid for care
or services could not exceed the Medicare rate, except in
highly rural areas, in the State of Alaska, in a State with an
All-Payer Model Agreement that became effective on January 1,
2014, or at other rates established by the Secretary if no
Medicare rate exists. The Secretary would be authorized to
recover from a third party for any care furnished for a non-
service-connected disability, and the Secretary would be
responsible for paying the copayment, deductible, or
coinsurance charged to the Veteran for care or services.
Veterans could not be required to pay a greater amount for
receiving care or services than they would if they had received
comparable care or services at a VA medical facility or from a
VA medical provider.
The proposed amendments to section 1703 would impose other
requirements. For example, VA would have to ensure the Veterans
Health Identification Card issued to every enrolled Veteran
includes the words ``Choice eligible'' and additional
information needed to serve as an identification card for the
Program. Additionally, the Secretary would be required to
monitor a number of quality and access standards related to the
care furnished under this Program. These changes would become
effective upon the termination of the current Veterans Choice
Program operated pursuant to section 101 of the Veterans
Access, Choice, and Accountability Act of 2014.
We support many of the principles in the proposed section
1703. We appreciate that the section's eligibility criteria
would be simple to administer by making every enrolled Veteran
eligible to participate. We also appreciate the flexibility in
terms of eligible providers, and the regional network model
generally matches our current plans with the Community Care
Network solicitation. We also appreciate the section's
recognition of the importance of ensuring quality care is
furnished to Veterans through this Program.
However, we have some significant concerns with certain
provisions of proposed section 1703. In many areas, there are
provisions that are overly prescriptive and that would narrow
the Secretary's authority to adjust to evolving situations. For
example, the Secretary would be prohibited from directing
Veterans to certain health care providers. While we support
Veterans' choosing their own providers, we understand that many
Veterans do not express a specific preference for an individual
provider, and this language could restrict our ability to
direct Veterans to high-performing providers who are available.
Also, the responsibilities of the regional networks are too
specific--we would prefer the language be silent on these
matters so that we can adjust responsibilities between VA and
our regional networks to ensure the best services are available
for Veterans. Furthermore, the language concerning payment
rates is too limiting. There will be situations where VA will
need to pay more than the Medicare rate other than in highly
rural areas, the State of Alaska, and States with All-Payer
Model Agreements. We have serious concerns with the language in
proposed 1703(h), which would require the Secretary to pay the
amount of a Veteran's copayment, deductible, or coinsurance.
This would be inconsistent with private sector and VA's current
practice. Section 1729 currently provides that Veterans are not
required to pay a copayment, deductible, or coinsurance
required under the terms of their health insurance for care and
services furnished by the Department. Moreover, requiring the
Department to pay a Veteran's copayment, deductible, or
coinsurance could significantly increase the Department's
expenses, including its administrative costs, in ways that we
cannot currently project given the variability in insurance
plans and payment responsibilities for the millions of Veterans
with such insurance. While we support the principle of ensuring
quality care, we are concerned that some of the language in
proposed 1703(l) would be too prescriptive, and we would prefer
more general language.
Requiring that the words ``Choice eligible'' appear on a
Veterans Health Identification Card (VHIC), as provided for in
proposed section 1703(k), would create redundancy and be
extremely costly. The bill would make any enrolled Veteran
eligible for Choice, and all enrolled Veterans are issued
VHICs, so any person with a VHIC would already establish his or
her eligibility by virtue of having the VHIC. Requiring
Veterans to have a VHIC with the words ``Choice eligible''
would also produce greater demands on Veterans who would have
to come to a VA facility to receive an updated version of their
VHIC.
Finally, we are concerned that there is no transition
period contemplated by section 3(a)(3). The new 1703 would take
effect immediately upon the expiration of the current Veterans
Choice Program, based on the exhaustion of the Veterans Choice
Fund. We believe that either a clear timeline (such as 1 year
from enactment) or an event within the Department's control
(such as the publication of regulations) would be preferable
for the transition between the current Choice Program and the
future Choice Program. We also may encounter problems where
individual authorizations made under the current 1703 would no
longer have any legal authority for payment upon this
transition, as this provision would completely rewrite section
1703. While the Department would try to reduce the potential
for this issue, we would not be able to eliminate this problem.
Section 3(b) would prohibit VA from entering into or
renewing any contract or agreement under a non-Department
provider program, which would include the current Veterans
Choice Program; the Patient-Centered Community Care (PC3)
program; the Project Access Received Closer to Home (ARCH)
program; VA's retail pharmacy network; agreements entered into
with DOD, IHS, or other Federal agencies; agreements entered
into with academic affiliates of VA; agreements to furnish
care, including on a fee basis; or agreements with non-
governmental entities. If the Secretary continued to administer
any of these programs after the date on which the new Veterans
Choice Program begins, they could only be administered under
that Program. The Secretary would be required to ensure
continuity of care by making services available through
regional contracts or other agreements entered into under the
new Veterans Choice Program.
We are very concerned with this provision and do not
support it. It would require VA to renegotiate, reissue, or
terminate every agreement and contract, regardless of the terms
or conditions of such an agreement permitting extensions or
other flexible authorities. We believe this could affect such
agreements as those with DOD, IHS, and tribal health programs,
as well as with our academic affiliates and contractors. This
would include thousands of agreements, would be very difficult
and costly to do, and would not produce any clear, tangible
benefit. If these agreements would also now be subject to the
limitations in proposed section 1703, this provision could put
conditions on these agreements that would be unacceptable to
certain providers or in certain areas. This could also
potentially impact our relationships with certain providers,
such as IHS and tribal health programs, which require
consultation prior to changes. We also note, given the breadth
of section 3(b)(4)(E), that extended care services procured
from the community would be included, but note that the
language for the Veterans Choice Program in section 1703 does
not address such services; as a result, it is unclear what
terms and conditions would apply to these services.
Section 4 would establish a new section 1703A authorizing
VA to enter into Veterans Care Agreements (VCA). VCAs could be
entered into when the Secretary is not feasibly able to furnish
hospital care, medical services, or extended care services at
VA facilities or when such care or services are not available
under the Veterans Choice Program. Providers could opt to enter
into a VCA, at the discretion of the eligible provider. The
eligibility of Veterans for care would be the same as if they
received care in a VA facility. The Secretary would be
prohibited from directing Veterans seeking care or services to
health care providers who have entered into contracts or
sharing agreements under different authorities, except for
Veterans Choice Agreements authorized under section 101 of the
Veterans Access, Choice, and Accountability Act of 2014 or
under the regional contracts or other arrangements made under
section 1703, as revised by section 3 of this bill.
The Secretary would be required to establish a process for
the certification of eligible providers. VCAs would have to
include certain terms, including accepting payment at Medicare
rates (except in highly rural or underserved areas), accepting
payment as payment in full, and other terms and conditions.
Each VCA would permit the provider to submit to the Secretary
clinical justification for any services furnished without
authorization when seeking payment, and the Secretary would
review these submissions on a case-by-case basis in determining
whether or to pay the provider for such services. The Secretary
would be required to review periodically VCAs of a material
size to determine whether it is feasible and advisable to
furnish the care and services at a VA facility or through
contracts or sharing agreements. VCAs would not be subject to
laws requiring competitive procedures in selecting the party
with which to enter the agreement. Parties entering into a VCA
would not be treated as a Federal contractor by the Office of
Federal Contract Compliance Programs (OFCCP) of the Department
of Labor, and they would not be subject to any laws that such a
provider would not be subject to under the original Medicare
fee-for-service program under Parts A and B of title XVIII of
the Social Security Act (42 U.S.C. 1395 et seq.), except for
laws applying to integrity, ethics, fraud, or that subject a
person to civil or criminal penalties. Title VII of the Civil
Rights Act of 1964 (42 U.S.C. 2000c et seq.) would apply to
parties entering into a VCA. The Secretary would be required to
establish a system or systems, consistent with those used by
the Centers for Medicare and Medicaid Services, to monitor the
quality of care provided and would be required to establish
administrative procedures for dispute resolution. The Secretary
would be required to prescribe an interim final rule within 1
year of enactment to carry out this section.
We generally support this provision, but have some concerns
we would like to address. In particular, proposed section
1703A(a)(2)(A)(ii) would prohibit the Secretary from entering
into a VCA if care or services are available under the new
Veterans Choice Program. Although we appreciate the intent of
this provision, we believe there may be situations where the
clinical need of the Veteran will require the use of a VCA
notwithstanding the availability of such services under the
Choice Program. For example, a Veteran may require a certain
type of orthopedic procedure, and while orthopedics in general
are ``available'' under a contract, the specific procedure or a
specialist may not be included within the contract, or would
only be available at a lesser quality. In other situations, a
Veteran may elect to receive care from a certain provider that
would be ideally suited to furnishing the care required, but
who is not a member of the network. We want to ensure we have
flexibility in situations like these to deliver the care the
Veteran requires in a timely and appropriate way. We also note
these provisions apply for when the Secretary may ``enter
into'' agreements, rather than ``use'' agreements. We have
found, through our experience with the current Veterans Choice
Program that it is more efficient to enter into these
agreements before they are needed to ensure that there is no
delay in the receipt of care by eligible Veterans. We believe
the language could be modified slightly to impose restrictions
on the utilization of VCAs to ensure the integrity and use of
the network of providers under the new Veterans Choice Program.
Proposed section 1703A(e)(2) is unclear, and depending upon
what the intent is, we may or may not support it. If the
provision is intended to simply allow providers to submit
claims for care that was unconnected or unrelated to the
services VA originally authorized, we are concerned this could
create situations where VA pays for services that were neither
authorized nor clinically needed. This would create a
significant administrative burden on both the providers and VA.
If, on the other hand, this is intended to apply only in
limited circumstances for care that VA would have authorized,
then we have no objection to it.
Regarding proposed section 1703A(g), VA agrees with the
idea of monitoring how VCAs are utilized by VA. However, we are
concerned that the threshold for when an agreement for the
purchase of extended care services is considered to be of
``material size,'' i.e., exceeding ``$1,000,000 annually,'' is
too low. Costs for long term extended care and nursing home
care costs can easily exceed this level. The threshold also
does not account for providers who may have a national
presence.
Section 5(a) would establish a new section 1703B concerning
payment of non-Department health care providers. Specifically,
VA would be required to comply with the provisions in this
section and in chapter 39 of title 31 (the Prompt Payment Act).
Non-Department providers would be required to submit a claim
for reimbursement within 180 days, and the Secretary would have
to pay claims according to specified time standards or else
interest would accrue on the amount owed. If a provider submits
a clean claim, VA would have to pay the claim within 30 days if
it was submitted electronically or 45 days if it was submitted
other than electronically. If a claim were not clean, the
Secretary would have to inform the provider within 10 days on
the steps that would be needed to make it clean. By January 1,
2020, the Secretary would only be authorized to accept claims
electronically except in certain circumstances.
We generally support section 5(a), but have some concerns
with a few of the provisions. For example, we think there
should be more flexibility to accept paper claims from smaller
providers, such as Homemaker/Home Health Aides. We are also
concerned that, as written, this language could require that
late payments of providers who have entered into contracts with
the Regional Networks could subject VA to interest payments,
even though VA has no privity of contract with these providers
and is paying the Network on time. Finally, we do not believe
the Committee had transactions between VA and other Federal
entities in mind when it included a prompt payment standard in
the draft bill. An exception could be added in this section to
address this issue.
Section 5(b) would require the Secretary, not later than 2
years after the date of the enactment of this Act, to enter
into an agreement with a third-party entity to process claims
for reimbursement through an electronic interface.
We are concerned about the intended scope of this
provision. If the electronic interface processing the claims is
only preparing them for adjudication and approval by VA, we do
not support this provision because VA is currently working on a
process internally that would perform this function. If the
term ``process'' is intended to cover adjudication and payment
as well, we would like to discuss with the Committee our
reservations about such an arrangement and propose potential
alternatives instead.
Section 6 would amend section 1745 to authorize the
Secretary to enter into agreements with State Veterans Homes
that would not be subject to laws requiring competitive
procedures in selecting the party with which to enter the
agreement. State Homes entering into these agreements would not
be subject to any laws that such a provider would not be
subject to under the original Medicare fee-for-service program
under Parts A and B of title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.), except for laws applying to
integrity, ethics, fraud, or that subject a person to civil or
criminal penalties. Title VII of the Civil Rights Act of 1964
(42 U.S.C. 2000c et seq.) would apply to State homes entering
into these agreements. These changes would become effective
upon the Secretary's publishing regulations to implement these
new authorities.
We generally support section 6, although, we have similar
concerns to those we expressed regarding section 4 with respect
to the applicability of certain laws.
Section 7 would amend section 1705 to require the
Secretary, upon the enrollment of a Veteran in the VA health
care system, to assign the Veteran to a dedicated primary care
provider of the Department, unless the Veteran elects to choose
a primary care provider from among the health care providers
furnishing care in the network established under the new
Veterans Choice Program.
We do not support section 7 because this would require all
enrolled Veterans to be enrolled in provider panels, even if we
do not furnish care to those Veterans. We typically only assign
Veterans to a panel once they have expressed interest in
receiving care from the Department. We are concerned that
assigning other Veterans to panels will complicate our
projection models for demand and our estimates for resources
for our facilities. We are also concerned that the ability of a
Veteran to elect to choose a primary care provider from among
VA's network of community providers could allow for the control
and coordination of care, including the authorization of care
(and the obligation of Federal funds), to move to a non-Federal
agent, which presents issues concerning the proper use of
appropriated funds.
Section 8 would require the Secretary to enter into
national contracts with private health care providers to make
dialysis treatments available in the community. Veterans would
be able to choose the provider from which they would receive
dialysis services. Under subsection (c), the Secretary could
not pay more than the Medicare rate for the same dialysis
services or treatment.
While we support the intent of this proposal, we are
concerned that this could potentially limit the Department's
ability to furnish dialysis care. This provision would limit VA
to paying the Medicare rate; we currently pay more than the
Medicare rate in certain circumstances, and it is unclear if we
could enter into contracts for the same care at a reduced rate.
If we were unable to enter into these contracts, VA would not
be able to provide this essential clinical service.
Section 9 would require VA to establish a demand profile
with respect to each health service furnished under the laws
administered by the Secretary. The demand profile would have to
include various factors, such as the number of requests for
services, the number of appointments (both in VA and the
community), the capacity of the Department to provide such
services, and an assessment of the need for community care for
the service. The Secretary would use these profiles to inform
the capability and capacity of the provider networks
established in the new Veterans Choice Program. Within 120 days
of the date of enactment of this Act, the Secretary would be
required to submit to Congress a strategic plan with a 5 year
forecast on the demand for care and the Department's capacity
and capability to satisfy that demand within its facilities.
The Secretary would have to update the strategic plan annually.
VA agrees in concept with the provisions in section 9;
however, we believe this provision is not necessary as VA has
currently embarked upon a national market-by-market assessment
effort that will produce the same level of information called
for in the bill. VA's market-by-market assessment is in
response to a requirement in section 240 of Division A of
Public Law 114-223, the ``Military Construction, Veterans
Affairs, and Related Agencies Appropriations Act, 2017.'' That
law requires VA to develop a national realignment strategy. As
a result, the assessment of VA's 98 marketplaces across the
United States is currently underway.
Section 10 would require the Secretary to establish uniform
access standards for furnishing health care services, including
through community providers, for urgent care, routine care,
referral or specialty care, and wellness or preventive care.
These access standards would have to include the average time a
Veteran is expected to wait to receive an appointment, the
average time a Veteran is expected to drive to arrive at an
appointment, the average time a Veteran is expected to wait at
a facility to receive health care services, and such other
factors as the Secretary considers appropriate. The Secretary
would be required to coordinate with DOD, the Department of
Health and Human Services (HHS), private entities, and other
non-governmental entities in establishing these standards. The
Secretary would be required to submit a report to Congress
within 120 days of the date of the enactment of this Act
detailing the standards established under this section.
We do not have views on section 10 at this time.
Section 11 would require the Secretary, within 1 year of
enactment, to procure a commercial, off-the-shelf electronic
health record platform that conforms to the standards of
interoperability required under section 713 of the National
Defense Authorization Act for Fiscal Year 2014. The bill would
define a number of requirements for this system, including its
interoperability with DOD's systems and private sector systems
and compliance with national standards identified by the VA and
the DOD Interagency Program Office in collaboration with HHS'
Office of the National Coordinator for Health Information
Technology.
VA does not believe section 11 is necessary because the
Secretary has already announced his intention to procure a
commercial system for VA's Electronic Health Record capability.
Similar to our concern with other provisions, we note that the
specificity in this provision could limit the Secretary's
ability to ensure this new system is responsive to Veterans'
needs.
Finally, section 12 would make various conforming
amendments to reflect the changes made by section 3 of this
bill by updating references in other statutes to VA's community
care authorities.
We support section 12 as a measure to consolidate VA's
community care programs.
We are unable to provide cost estimates on the bill at this
time but will follow up after the hearing with any estimates we
can develop and our thoughts on the potential budget
implications. We will also provide technical comments for your
consideration.
S. XXXX--IMPROVING VETERANS ACCESS TO COMMUNITY CARE ACT OF 2017
The draft Improving Veterans Access to Community Care Act
of 2017 also contains a number of provisions intended to
improve VA's community care program.
Section 101(a)(1) would create a new section 1703A,
establishing the Veterans Community Care Program. Many of the
terms and conditions governing this Program would be similar to
those applicable to the existing Veterans Choice Program. Under
this new Program, hospital care and medical services would be
furnished to eligible Veterans at the election of the Veteran
through contracts or agreements with eligible providers. The
Secretary would be responsible for coordinating care and
services, including ensuring that an eligible Veteran receives
an appointment for care and services within the wait-time goals
of the Veterans Health Administration (VHA). To be eligible
under the Program, Veterans would have to be enrolled in VA
health care and meet one of the following criteria: reside in a
location, other than Guam, American Samoa, or the Republic of
the Philippines that requires the Veteran to travel by air,
boat or ferry to reach a VA medical facility; be enrolled in
Project ARCH; the Veteran and the Veteran's VA provider
determine the Veteran should be eligible based upon the
eligibility criteria in the current Veterans Choice Program,
namely being unable to schedule an appointment within the
clinically indicated timeframe, residing more than 40 miles
driving distance from the nearest VA medical facility with a
full-time primary care physician, residing within a State
without a full-service VA medical center, or facing an unusual
or excessive burden in accessing services from a VA medical
facility. The Veteran and provider could also determine whether
the Veteran should be eligible under the Program based upon a
compelling reason that the Veteran needs to receive care and
services from a non-Department facility. The Secretary would be
required to establish a process to review any disagreement
between Veterans and their providers, and the Secretary would
make the final determination as to the eligibility of the
Veteran.
While we appreciate the intent of the eligibility criteria
for Veterans, we are concerned with how this program is
structured. We fully agree that the provider-patient
relationship should be the basis for eligibility to receive
community care. However, the draft bill would combine this
approach with the current administrative eligibility criteria
in the Choice Program. We believe this would result in an
ultimately confusing ``hybrid'' standard that would be
difficult for providers to apply. In addition, we believe
continuing to use administrative criteria would be
inappropriate, as they are arbitrary in nature and not informed
by the patient-provider relationship. The proposed approach
would also be unduly limiting in terms of the types of clinical
factors that a provider could consider; for example, a Veteran
who lived across the street from a full-service VA medical
center with no wait times and who was fully ambulatory would
not appear to qualify under any of these provisions, and yet
the Veteran may require a certain type of service that would be
best delivered by a community provider. We would like to work
with the Committee to better understand the underlying issue
that proposed subsection (b)(2), concerning the review of
provider determinations, is intended to address.
Under section 1703A, providers would have to meet the same
eligibility criteria in the current Veterans Choice Program to
participate in the new Program, including maintaining the same
or similar credentials and licenses as VA providers. The
Secretary would be authorized to create a tiered provider
network, but would not be able to prioritize providers in a
tier over providers in any other tier in a manner that limits
the choice of an eligible Veteran to select that provider. The
Secretary would be required to enter into contracts with
eligible providers for furnishing care and services, but before
entering into such a contract, the Secretary would be required,
to the maximum extent practicable and consistent with the
requirements of this section, to furnish care and services with
eligible providers pursuant to sharing agreements, existing
contracts, or other processes available for procuring care. In
this section, the term ``contract'' would have the definition
given that term in subpart 2.101 of the Federal Acquisition
Regulations. Providers would be paid under a negotiated rate
that, to the extent practicable, would not exceed the Medicare
rate, with limited exceptions for highly rural areas, Alaska,
and States with an All-Payer Model Agreement. Eligible
providers would be prohibited from collecting any amount
greater than the negotiated rate. The Secretary would be
authorized in negotiating rates to incorporate the use of
value-based reimbursement models to promote the provision of
high-quality care. The Secretary would be authorized to collect
from third-parties the costs of furnishing care for non-
service-connected disabilities under this section, and such
collections would be deposited into the Medical Community Care
account and remain available until expended.
We do not support the provision requiring providers to
maintain the same or similar credentials and licenses as VA
providers; while this is a requirement in the current Veterans
Choice Program, we have found it to be administratively
difficult (and at times impossible) to implement in certain
situations. We believe strongly in the importance of ensuring
our providers furnish quality care, but recommend a different
approach than this obligation. We are also concerned that some
of the language regarding the terms of the agreements with
providers contemplates a direct relationship between VA and the
providers, rather than a relationship between VA and a network
administrator, and a separate relationship between the
administrator and the provider. Similarly, we do not support
the provision that would require the deposit of collected funds
into the Medical Community Care account. Funds collected by VA
under sections 1725 and 1729 of title 38, and section 2651 of
title 42 are currently deposited in the Medical Care
Collections Fund, where they may be used to support both VA and
community care. We believe creating a separate collection
account would be duplicative and would limit our funding
flexibility. Finally, we note that referencing the definition
of ``third party'' in section 1729 produces a narrower effect
than if the definition in section 1725 were referenced.
The Secretary would be required to provide Veterans
information about this Program upon their enrollment and when
they become eligible based on a determination between the
Veteran and his or her provider. The Secretary would be
required to ensure that follow up care, including specialty and
ancillary services deemed necessary, are furnished through the
Program at the election of the Veteran. Veterans would be
required to pay a copayment for care under this Program, but
the copayment could be no more than what the Veteran would owe
if such care or services were furnished directly by the
Department. The Secretary would also be required to establish a
claims processing system to ensure prompt and accurate payment
of bills and claims for authorized care. Under subsection (j),
a Veteran's election to receive care under this Program would
serve as written consent for purposes of section 7332(b)(1),
which governs the disclosure of certain protected health
information. Providers would be required under subsection
(k)(1) to submit copies of the Veteran's medical records upon
the completion of the provision of such care and services, but
these records could not be required prior to reimbursement.
Under subsection (m), the Secretary would be required to track
missed appointments to ensure the Department does not pay for
care or services that were not rendered.
We note that subsection (j) is no longer needed given the
amendments to section 7332 made by Public Law 115-26. In terms
of subsection (k)(1), we believe it would be better for the
records to be required as determined by the Secretary to ensure
that the records are provided in a timely fashion and that care
provided by VA and others is informed. We also recommend
against including subsection (m), regarding the tracking of
missed appointments, as our experience with the current
Veterans Choice Program has proven this difficult to implement.
We have taken other precautions to ensure the Department is not
paying for care and services that were not provided, and we
believe this approach is more suitable for the legislation's
intent.
Section 101(a)(3) would terminate the current Veterans
Choice Program authority and make other conforming amendments.
We do not support this provision, as the Department will
need a transition period during which it can prepare for the
future of community care while still ensuring Veterans receive
care through the current Choice Program.
Section 101(a)(4) would require a report within 1 year of
the date of enactment of this Act providing information about
services rendered under the new Program.
We note that subparagraph (D) of this provision would
require a report on the results of a survey of Veterans who
have received care or services under this program. Given the
time it may take us to develop a survey, VA may not be able to
gather meaningful information in the time between OMB approval
of the information collection and the reporting deadline.
Regarding subparagraph (E), which would require an assessment
of the effect of furnishing care and services under new section
1703A on wait times, we have not found reliable data that would
support a firm assessment through the current Choice Program,
and we believe we would encounter the same issues under this
proposal.
Section 101(b) would provide that services under various
programs and authorities be considered services under the
Veterans Community Care Program established under the new
section 1703A, including PC3, contracts through VA's retail
pharmacy network, VCAs, and health care agreements with other
Federal and non-Federal agencies.
We are not sure exactly what it means for services under
another program to be ``considered'' services under the
Veterans Community Care Program. If this would require that all
of the agreements and programs identified in this subsection
meet the terms and conditions of the Veterans Community Care
Program, we would not support that requirement.
Section 101(c) would state that all amounts required to
carry out the new Program would be derived from the Medical
Community Care account, and that all amounts in the Veterans
Choice Fund would be transferred to the Medical Community Care
account. Section 802 of the Veterans Access, Choice, and
Accountability Act of 2014 would be repealed, and conforming
amendments would be made to section 4003 of the Surface
Transportation and Veterans Health Care Choice Improvement Act
of 2015.
We agree with the importance of consolidating funding for
community care, but we recommend that the transfer of funds
from and the repeal of the Veterans Choice Fund only apply to
unobligated funds and provide a delayed effective date to
support the transition from the current program to the future
program.
Section 101(d) would require, within 90 days of the
enactment of this Act, the Secretary to establish consistent
criteria and standards for furnishing non-Department care,
including the eligibility requirements of providers and
reimbursement rates (which, to the extent practicable, would be
the Medicare rate). These standards would not apply to the
Veterans Community Care Program established under section
101(a)(1).
We support the intent of subsection (d). We have minor
technical recommendations that we would be pleased to discuss
with the Committee.
Section 101(e) would require the Secretary to establish a
working group to assess the feasibility and advisability of
considering under subsection (b) services under health care
agreements with health care providers of the Indian Health
Service (IHS) and tribal health programs to be provided under
the Veterans Community Care Program. The working group would
include representatives of IHS, tribal health programs, and
Veterans who receive services from either IHS or tribal health
programs. Within 180 days of enactment of this Act, the working
group would be required to submit a report to the Secretary on
the feasibility and advisability of considering such services
to be services under the Veterans Community Care Program, and
within 90 days of receiving this report, the Secretary would be
required to submit a report to Congress on the feasibility and
advisability of implementing the working group's
recommendations.
We do not oppose greater coordination and discussion with
IHS or tribal health programs, but we do not believe the
timelines in the legislation are realistic. We also do not
believe it is necessary to require this coordination in law, as
we are already working with these groups to improve cultural
understanding and resource sharing. We also note that the
Federal Advisory Committee Act (FACA) would likely apply to the
working group, given the inclusion of non-government personnel.
Section 102(a) would create a new section 1703B regarding
prompt payment of providers. It would require substantially the
same things required by section 5(a) of the draft Veterans
Choice Act of 2017, with a few exceptions. For example, this
bill would authorize the Secretary to accept claims and medical
records submitted other than electronically if the Secretary
determines the provider is unable to submit claims or medical
records electronically. It would also authorize the Secretary
to accept non-electronic claims if the Secretary determines
doing so is necessary for the timely processing of claims due
to a failure or serious malfunction of the electronic interface
of the Department (required in section 102(b)) for submitting
claims.
As discussed with respect to section 5(a) of the draft
Veterans Choice Act of 2017, we generally support these
provisions and appreciate the flexibility contained in this
version.
Section 102(b) would require, not later than January 1,
2019, the Chief Information Officer of the Department to
establish an electronic interface for health care providers to
submit claims for reimbursement under section 1703B. The bill
would define various requirements in terms of functions of the
interface and protection of information. By January 1, 2018, or
before entering into a contract to procure or design and build
such an interface, the Secretary would be required to conduct
an analysis to determine whether it would be better to build or
buy such an interface and submit a report on such analysis to
Congress. The bill would define various requirements of this
analysis and report, and the Secretary would not be authorized
to spend any amounts to procure or design and build the
electronic interface until 60 days after the required report is
submitted to Congress.
We are concerned about the intended scope of this
provision. If the electronic interface processing the claims is
only preparing them for adjudication and approval by VA, we do
not support this provision because VA is currently working on a
process internally that would perform this function. If the
provision is intended to cover adjudication and payment as
well, we would like to discuss with the Committee our
reservations about such an arrangement and propose potential
alternatives instead. We also caution that the deadline in
subsection (b)(2) of January 1, 2018, for making a decision to
internally design and build or enter into a contract to procure
an electronic interface is likely too soon, given the
uncertainty regarding community care funding, continuing
developments of the design of the new EHR, and the potential
implications to other information technology projects.
Section 103 would amend 38 U.S.C. Sec. 1151(a) by adding a
paragraph that would require VA to pay compensation if a
Veteran's disability or death was caused by hospital care or
medical services furnished under proposed section 1703A of
title 38, United States Code, and the proximate cause of the
disability or death was carelessness, negligence, lack of
proper skill, error in judgment, or similar instance of fault
by the provider or an event not reasonably foreseeable.
VA fully supports ensuring that Veterans have access to
high quality care, and that they are made whole in the event of
a medical error. However, VA does not support this provision as
written based on several concerns. First, section 103 would
expand section 1151(a) to require VA benefit payments where the
``proximate cause'' of a Veteran's disability or death was the
negligence of a non-Department health care provider or an
unforeseeable event occurring during treatment by such a
provider. The ``term 'proximate cause' is used to label
generically the judicial tools used to limit a person's
responsibility for the consequences of that person's own acts.
At bottom, the notion of proximate cause reflects 'ideas of
what justice demands, or of what is administratively possible
and convenient.''' Holmes v. Sec. Investor Prot. Corp., 503
U.S. 258, 268 (1992) (quoting W. Keeton, D. Dobbs, R. Keeton, &
D. Owen, Prosser and Keeton on Law of Torts Sec. 41, p. 264
(5th ed. 1984)). Section 103 would make the Federal government
liable for disability or death that is the proximate result of
a non-Department medical provider's negligence or an
unforeseeable event. This is contrary to the basic principle of
American law, which holds an individual legally responsible for
injuries caused by his or her negligent conduct.
Second, VA adjudicators would be required to develop
evidence regarding care that is not provided by VA employees or
in VA facilities, including DOD and other Federal health care
providers and academic affiliates, and to determine whether a
Veteran's disability was proximately caused by negligence on
the part of the community provider or an unforeseeable event
occurring during non-Department medical care. See 38 U.S.C.
Sec. 5103A. This would entail gathering medical and other
records from community providers as well as expert medical
opinions about whether the event that occurred during the non-
Department treatment was not foreseeable. This development
burden of obtaining and evaluating evidence from non-Department
providers and facilities can be expected to slow the
adjudication of other Veterans' claims for benefits and
potentially add to the disability compensation backlog.
Third, under 38 U.S.C. '1151(b), a recovery under the
Federal Tort Claims Act as a result of a judgment or settlement
for a disability or death for which compensation is awarded
under 38 U.S.C. Sec. 1151(a) results in a suspension of the
section 1151 benefits until the amount of the judgment or
settlement is recouped. In contrast, section 103 does not
provide for a suspension of compensation for any recovery by a
Veteran or Veteran's survivors from the non-Department provider
as a result of a private lawsuit based upon the same disability
or death. As a result, a Veteran or a Veteran's survivor could
receive a recovery of both section 1151 benefits and tort
damages based upon a judgment or settlement. This would create
an inequity by allowing duplicative recovery for the same
disability or death for persons whose entitlement is based on
care furnished by community providers.
We have not yet had time to estimate the costs for section
103. However, we do know that, in FY 2016, 2.2 million Veterans
received care from community providers under existing VA
statutory authorities. During the first three quarters of FY
2017, 1.2 million Veterans have received such care. VA
purchases care from more than 500,000 community providers, and
the number continues to grow. VA's FY 2018 budget requests a 13
percent increase in funding for community care. As a result, VA
could potentially be liable for section 1151 benefits for any
of these 2 million Veterans who suffer additional disability or
death due to negligence or an unforeseeable event caused by
community care provided by community providers despite the
absence of a causal connection between the additional
disability or death and VA medical treatment.
Section 104 would add a sunset provision to section 1703 of
title 38 terminating that program on December 31, 2018. It
would make other conforming amendments similar to those
proposed in section 12 of the draft Veterans Choice Act of
2017.
We support section 104.
Section 201 would add a new section 1703C to authorize the
Secretary to enter into VCAs, similar to the authority that
would be provided under section 4 of the draft Veterans Choice
Act of 2017. However, there are a few differences in the
proposed section 1703C that section 201 would create. First,
the draft Veterans Choice Act of 2017 would require that care
be unavailable under the Veterans Choice Program established in
that draft bill prior to entering into a VCA, while the
Improving Veterans Access to Community Care Act of 2017 has no
such limitation. The draft Veterans Choice Act of 2017 would
authorize providers to opt out of a VCA, but the Improving
Veterans Access to Community Care Act of 2017 does not include
this provision. The draft Veterans Choice Act of 2017 would
limit the ability of the Secretary to direct patients to
providers that have entered into contracts or agreements under
other authorities, while the Improving Veterans Access to
Community Care Act of 2017 does not include such a restriction.
The draft Improving Veterans Access to Community Care Act of
2017 would include greater flexibility in terms of the Medicare
rate through inclusion of the phrase ``to the extent
practicable'' in prescribing the rates the Secretary would pay
under VCAs. While we believe the draft Veterans Choice Act of
2017 would allow the Secretary, on a case-by-case basis, to
determine whether or not to pay for care not authorized, the
Improving Veterans Access to Community Care Act of 2017 would
allow the Secretary to pay a provider who provides services in
the course of treatment pursuant to an agreement with the
Secretary but is not a party to the agreement. Finally, the
draft Veterans Choice Act of 2017 would state uniformly that
the OFCCP would not have authority over parties to a VCA,
while, through section 205, the Improving Veterans Access to
Community Care Act of 2017 would apply the limits established
for the TRICARE Program in Directive 2014-01 of OFCCP to any
health care provider entering into an agreement or contract
with VA under section 1703A, 1703C, or 1745.
We support section 201 and prefer those provisions that
differ from the draft Veterans Choice Act of 2017.
Section 205 would apply the OFCCP moratorium to VA, and VA
supports that provision. We recommend against including a
specific deadline, as that would allow flexibility in the event
that the OFCCP Directive is further revised. Many of the
technical concerns we identified with the draft Veterans Choice
Act of 2017 regarding VCAs apply here as well, and we look
forward to working with the Committee and the Department of
Labor to address concerns.
Section 202 would modify VA's authority under section 1745
and is identical to section 6 of the draft Veterans Choice Act
of 2017.
VA's views on that provision apply here as well.
Section 203 would amend section 106 of the Veterans Access,
Choice, and Accountability Act of 2014 to require that, at the
beginning of each fiscal year, the Secretary to transfer to VHA
an amount equal to the estimated amount required to furnish
hospital care, medical services, and other health care through
non-Department providers during the fiscal year. The Secretary
would be authorized to make adjustments to the amount
transferred to accommodate variances in demand for such care
and services from non-Department providers.
We support section 203 because this would provide greater
flexibility to adjust resource allocations based upon actual
demand.
Section 204 would create a new section 1730B, which would
allow the Secretary, notwithstanding sections 1341(a)(1) and
1501 of title 31, to record an obligation of the United States
for non-Department care on the date on which a claim for
payment is approved, rather than the date on which the care or
services are authorized.
VA understands this provision is intended to bring the
Department closer to industry practices in terms of allocating
resources for care and developing better estimates concerning
our community care liabilities. VA appreciates the Committee's
willingness to engage on this issue given our prior discussions
on this, and we look forward to working with you further on
this proposal.
Section 205 of the bill is discussed above in the analysis
of section 201, and the Department's views on this provision
are provided in that discussion.
We are unable to provide cost estimates on the bill at this
time, but will follow up after the hearing with any estimates
we can develop and our thoughts on the potential budget
implications. We will also provide technical comments for your
consideration.
Mr. Chairman, this concludes my statement. I would be happy
to answer any questions you or Members of the Committee may
have.
Title 38. Veterans' Benefits
* * * * * * *
Part I. General Provisions
* * * * * * *
Chapter 7. Employees
SUBCHAPTER I. GENERAL EMPLOYEE MATTERS
Sec.
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725. Annual performance plan for political appointees.
726. Annual report on performance awards and bonuses awarded to
certain high-level employees.
* * * * * * *
Subchapter I. General Employee Matters
* * * * * * *
SEC. 726. ANNUAL REPORT ON PERFORMANCE AWARDS AND BONUSES AWARDED TO
CERTAIN HIGH-LEVEL EMPLOYEES
(a) In General.--Not later than 30 days after the end of
each fiscal year, the Secretary shall submit to the appropriate
committees of Congress a report that contains, for the most
recent fiscal year ending before the submittal of the report, a
description of the performance awards and bonuses awarded to
Regional Office Directors of the Department, Directors of
Medical Centers of the Department, and Directors of Veterans
Integrated Service Networks.
(b) Elements.--Each report submitted under subsection (a)
shall include the following with respect to each performance
award or bonus awarded to an individual described in such
subsection:
(1) The amount of each award or bonus.
(2) The job title of the individual awarded the award
or bonus.
(3) The location where the individual awarded the
award or bonus works.
(c) Appropriate Committees of Congress.--In this section,
the term ``appropriate committees of Congress'' means--
(1) the Committee on Veterans' Affairs and the
Committee on Appropriations of the Senate; and
(2) the Committee on Veterans' Affairs and the
Committee on Appropriations of the House of
Representatives.
Part II. General Benefits
Chapter 17. Hospital, Nursing Home, Domiciliary, and Medical Care
SUBCHAPTER I. GENERAL
Sec.
1701. Definitions.
1702. Presumptions: psychosis after service in World War II and
following periods of war; mental illness following
service in the Persian Gulf War.
[1703. Contracts for hospital care and medical services in non-
Department facilities.]
1703. Veterans Community Care Program.
1703A. Agreements with eligible entities or providers;
certification processes.
1703B. Access guidelines.
1703C. Standards for quality.
1703D. Prompt payment standard.
1704. Preventive health services: annual report.
* * * * * * *
SUBCHAPTER III. MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND
NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS
* * * * * * *
1725.Reimbursement for emergency treatment.
1725A. Access to walk-in care.
* * * * * * *
1730B. Licensure of health care professionals providing treatment
via telemedicine.
* * * * * * *
SUBCHAPTER VIII. HEALTH CARE OF PERSONS OTHER THAN VETERANS
* * * * * * *
1788. Transplant procedures with live donors and related
services.
Subchapter I. General
* * * * * * *
[SEC. 1703. CONTRACTS FOR HOSPITAL CARE AND MEDICAL SERVICES IN NON-
DEPARTMENT FACILITIES
[(a) When Department facilities are not capable of
furnishing economical hospital care or medical services because
of geographical inaccessibility or are not capable of
furnishing the care or services required, the Secretary, as
authorized in section 1710 of this title, may contract with
non-Department facilities in order to furnish any of the
following:
[(1) Hospital care or medical services to a veteran
for the treatment of--
[(A) a service-connected disability;
[(B) a disability for which a veteran was
discharged or released from the active
military, naval, or air service; or
[(C) a disability of a veteran who has a
total disability permanent in nature from a
service-connected disability.
[(2) Medical services for the treatment of any
disability of--
[(A) a veteran described in section
1710(a)(1)(B) of this title;
[(B) a veteran who (i) has been furnished
hospital care, nursing home care, domiciliary
care, or medical services, and (ii) requires
medical services to complete treatment incident
to such care or services; or
[(C) a veteran described in section
1710(a)(2)(E) of this title, or a veteran who
is in receipt of increased pension, or
additional compensation or allowances based on
the need of regular aid and attendance or by
reason of being permanently housebound (or who,
but for the receipt of retired pay, would be in
receipt of such pension, compensation, or
allowance), if the Secretary has determined,
based on an examination by a physician employed
by the Department (or, in areas where no such
physician is available, by a physician carrying
out such function under a contract or fee
arrangement), that the medical condition of
such veteran precludes appropriate treatment in
Department facilities.
[(3) Hospital care or medical services for the
treatment of medical emergencies which pose a serious
threat to the life or health of a veteran receiving
medical services in a Department facility or nursing
home care under section 1720 of this title until such
time following the furnishing of care in the non-
Department facility as the veteran can be safely
transferred to a Department facility.
[(4) Hospital care for women veterans.
[(5) Hospital care, or medical services that will
obviate the need for hospital admission, for veterans
in a State (other than the Commonwealth of Puerto Rico)
not contiguous to the contiguous States, except that
the annually determined hospital patient load and
incidence of the furnishing of medical services to
veterans hospitalized or treated at the expense of the
Department in Government and non-Department facilities
in each such noncontiguous State shall be consistent
with the patient load or incidence of the furnishing of
medical services for veterans hospitalized or treated
by the Department within the 48 contiguous States and
the Commonwealth of Puerto Rico.
[(6) Diagnostic services necessary for determination
of eligibility for, or of the appropriate course of
treatment in connection with, furnishing medical
services at independent Department out-patient clinics
to obviate the need for hospital admission.
[(7) Outpatient dental services and treatment, and
related dental appliances, for a veteran described in
section 1712(a)(1)(F) of this title.
[(8) Diagnostic services (on an inpatient or
outpatient basis) for observation or examination of a
person to determine eligibility for a benefit or
service under laws administered by the Secretary.
[(b) In the case of any veteran for whom the Secretary
contracts to furnish care or services in a non-Department
facility pursuant to a provision of subsection (a) of this
section, the Secretary shall periodically review the necessity
for continuing such contractual arrangement pursuant to such
provision.
[(c) The Secretary shall include in the budget documents
which the Secretary submits to Congress for any fiscal year a
detailed report on the furnishing of contract care and services
during the most recently completed fiscal year under this
section, sections 1712A, 1720, 1720A, 1724, and 1732 of this
title, and section 115 of the Veterans' Benefits and Services
Act of 1988 (Public Law 100-322; 102 Stat. 501).
[(d)(1) The Secretary shall conduct a program of recovery
audits for fee basis contracts and other medical services
contracts for the care of veterans under this section, and for
beneficiaries under sections 1781, 1782, and 1783 of this
title, with respect to overpayments resulting from processing
or billing errors or fraudulent charges in payments for non-
Department care and services. The program shall be conducted by
contract.
[(2) Amounts collected, by setoff or otherwise, as the
result of an audit under the program conducted under this
subsection shall be available, without fiscal year limitation,
for the purposes for which funds are currently available to the
Secretary for medical care and for payment to a contractor of a
percentage of the amount collected as a result of an audit
carried out by the contractor.
[(3) The Secretary shall allocate all amounts collected
under this subsection with respect to a designated geographic
service area of the Veterans Health Administration, net of
payments to the contractor, to that region.
[(4) The authority of the Secretary under this subsection
terminates on September 30, 2020.]
SEC. 1703. VETERANS COMMUNITY CARE PROGRAM
(a) In General.--(1) There is established a program to
furnish hospital care, medical services, and extended care
services to covered veterans through health care providers
specified in subsection (c).
(2) The Secretary shall coordinate the furnishing of
hospital care, medical services, and extended care services
under this section to covered veterans, including coordination
of, at a minimum, the following:
(A) Ensuring the scheduling of medical appointments
in a timely manner and the establishment of a mechanism
to receive medical records from non-Department
providers.
(B) Ensuring continuity of care and services.
(C) Ensuring coordination among regional networks if
the covered veteran accesses care and services in a
different network than the regional network in which
the covered veteran resides.
(D) Ensuring that covered veterans do not experience
a lapse resulting from errors or delays by the
Department or its contractors or an unusual or
excessive burden in accessing hospital care, medical
services, or extended care services.
(b) Covered Veterans.--For purposes of this section, a
covered veteran is any veteran who--
(1) is enrolled in the system of annual patient
enrollment established and operated under section 1705
of this title; or
(2) is not enrolled in such system but is otherwise
entitled to hospital care, medical services, or
extended care services under subsection (c)(2) of such
section.
(c) Health Care Providers Specified.--Health care providers
specified in this subsection are the following:
(1) Any health care provider that is participating in
the Medicare program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.), including any
physician furnishing services under such a program.
(2) The Department of Defense.
(3) The Indian Health Service.
(4) Any Federally-qualified health center (as defined
in section 1905(l)(2)(B) of the Social Security Act (42
U.S.C. 1396d(l)(2)(B))).
(5) Any health care provider not otherwise covered
under any of paragraphs (1) through (4) that meets
criteria established by the Secretary for purposes of
this section.
(d) Conditions Under Which Care Is Required To Be Furnished
Through Non-Department Providers.--(1) The Secretary shall,
subject to the availability of appropriations, furnish hospital
care, medical services, and extended care services to a covered
veteran through health care providers specified in subsection
(c) if--
(A) the Department does not offer the care or
services the veteran requires;
(B) the Department does not operate a full-service
medical facility in the State in which the covered
veteran resides;
(C) the covered veteran was an eligible veteran under
section 101(b)(2)(B) of the Veterans Access, Choice,
and Accountability Act of 2014 (Public Law 113-146; 38
U.S.C. 1701 note) as of the day before the date of the
enactment of the Caring for our Veterans Act of 2017;
or
(D) the covered veteran and the covered veteran's
primary care provider agree that furnishing care and
services through a non-Department entity or provider
would be in the best medical interest of the covered
veteran based upon criteria developed by the Secretary.
(2) The Secretary shall ensure that the criteria developed
under paragraph (1)(D) include consideration of the following:
(A) The distance between the covered veteran and the
facility that provides the hospital care, medical
services, or extended care services the veteran needs.
(B) The nature of the hospital care, medical
services, or extended care services required.
(C) The frequency that the hospital care, medical
services, or extended care services needs to be
furnished.
(D) Whether an appointment for the hospital care,
medical services, or extended care services the covered
veteran requires is available from a health care
provider of the Department within the lesser of--
(i) the access guidelines for such hospital
care, medical services, or extended care
services as established by the Secretary; and
(ii) a period determined by a health care
provider of the Department to be clinically
necessary for the receipt of such hospital
care, medical services, or extended care
services.
(E) Whether the covered veteran faces an unusual or
excessive burden to access hospital care, medical
services, or extended care services from the Department
medical facility where a covered veteran seeks hospital
care, medical services, or extended care services,
which shall include consideration of the following:
(i) Whether the covered veteran faces an
excessive driving distance, geographical
challenge, or environmental factor that impedes
the access of the covered veteran.
(ii) Whether the hospital care, medical
services, or extended care services sought by
the veteran is provided by a medical facility
of the Department that is reasonably accessible
to a covered veteran.
(iii) Whether a medical condition of the
covered veteran affects the ability of the
covered veteran to travel.
(iv) Whether there is compelling reason, as
determined by the Secretary, that the veteran
needs to receive hospital care, medical
services, or extended care services from a
medical facility other than a medical facility
of the Department.
(v) Such other considerations as the
Secretary considers appropriate.
(3) If the Secretary has determined that the Department
does not offer the care or services the covered veteran
requires under subparagraph (A) of paragraph (1), that the
Department does not operate a full-service medical facility in
the State in which the covered veteran resides under
subparagraph (B) of such paragraph, or that the covered veteran
is described under subparagraph (C) of such paragraph, the
decision to receive hospital care, medical services, or
extended care services under such subparagraphs from a health
care provider specified in subsection (c) shall be at the
election of the veteran.
(e) Conditions Under Which Care Is Authorized to Be
Furnished Through Non-Department Providers.--(1)(A) The
Secretary may furnish hospital care, medical services, or
extended care services through a health care provider specified
in subsection (c) to a covered veteran served by a medical
service line of the Department that the Secretary has
determined is not providing care that meets such quality and
access standards as the Secretary shall develop.
(B) In carrying out subparagraph (A), the Secretary shall--
(i) measure access of the medical service line at a
facility of the Department when compared with the same
medical service line at different Department
facilities; and
(ii) measure quality at a medical service line of a
facility of the Department by comparing it with two or
more distinct and appropriate quality measures at non-
Department medical service lines.
(C)(i) The Secretary may not concurrently furnish hospital
care, medical services, or extended care services under
subparagraph (A) with respect to more than three medical
service lines described in such subparagraph at any one health
care facility of the Department.
(ii) The Secretary may not concurrently furnish hospital
care, medical services, or extended care services under
subparagraph (A) with respect to more than 36 medical service
lines nationally described in such subparagraph.
(2) The Secretary may limit the types of hospital care,
medical services, or extended care services covered veterans
may receive under paragraph (1) because of an access and
quality deficiency of a medical service line in terms of the
length of time such care and services will be available, the
location at which such care and services will be available, and
the clinical care and services that will be available.
(3) The hospital care, medical services, and extended care
services authorized under paragraph (1) with respect to a
medical service line shall cease when the remediation described
in subsection (g) with respect to such medical service line is
complete.
(4) The Secretary shall publish in the Federal Register,
and shall take all reasonable steps to provide direct notice to
covered veterans affected under this subsection, at least once
each year stating the time period during which such care and
services will be available, the location or locations where
such care and services will be available, and the clinical
services available at each location under this subsection in
accordance with regulations the Secretary shall prescribe.
(5) When the Secretary exercises the authority under
paragraph (1), the decision to receive care or services under
such paragraph from a health care provider specified in
subsection (c) shall be at the election of the covered veteran.
(f) Review of Decisions.--The review of any decision under
subsection (d) or (e) shall be subject to the Department's
local clinical appeals process, and such decisions may not be
appealed to the Board of Veterans' Appeals.
(g) Remediation of Medical Service Lines.--(1) Not later
than 30 days after determining under subsection (e)(1) that a
medical service line of the Department is providing hospital
care, medical services, or extended care services that does not
comply with the access guidelines and meet the standards of
quality established by the Secretary, the Secretary shall
submit to Congress an assessment of the factors that led the
Secretary to make such determination and a plan with specific
actions, and the time to complete them, to be taken to comply
with such access guidelines and meet such standards of quality,
including the following:
(A) Increasing personnel or temporary personnel
assistance, including mobile deployment teams.
(B) Special hiring incentives, including the
Education Debt Reduction Program under subchapter VII
of chapter 76 of this title and recruitment,
relocation, and retention incentives.
(C) Utilizing direct hiring authority.
(D) Providing improved training opportunities for
staff.
(E) Acquiring improved equipment.
(F) Making structural modifications to the facility
used by the medical service line.
(G) Such other actions as the Secretary considers
appropriate.
(2) In each assessment submitted under paragraph (1) with
respect to a medical service line, the Secretary shall identify
the individuals at the Central Office of the Veterans Health
Administration, the facility used by the medical service line,
and the central office of the relevant Veterans Integrated
Service Network who are responsible for overseeing the progress
of that medical service line in complying with the access
guidelines and meeting the standards of quality established by
the Secretary.
(3) Not later than 180 days after submitting an assessment
under paragraph (1) with respect to a medical service line, the
Secretary shall submit to Congress a report on the progress of
that medical service line in complying with the access
guidelines and meeting the standards of quality established by
the Secretary and any other measures the Secretary will take to
assist the medical service line in complying with such access
guidelines and meeting such standards of quality.
(4) Not less frequently than once each year, the Secretary
shall--
(A) submit to Congress an analysis of the remediation
actions and costs of such actions taken with respect to
each medical service line with respect to which the
Secretary submitted an assessment and plan under
paragraph (1) in the preceding year, including an
update on the progress of each such medical service
line in meeting the quality and access standards
established by the Secretary and any other actions the
Secretary is undertaking to assist the medical service
line in complying with access guidelines and meeting
standards of quality as established by the Secretary;
and
(B) publish such analysis on the Internet website of
the Department.
(h) Access Guidelines and Standards for Quality.--(1) The
Secretary shall establish access guidelines under section 1703B
of this title and standards for quality under section 1703C of
this title for furnishing hospital care, medical services, or
extended care services to a covered veteran for the purposes of
subsections (d) and (e).
(2) The Secretary shall ensure that the access guidelines
and standards for quality required by sections 1703B and 1703C
of this title provide covered veterans, employees of the
Department, and health care providers in the network
established under subsection (j) with relevant comparative
information that is clear, useful, and timely, so that covered
veterans can make informed decisions regarding their health
care.
(3) The Secretary shall consult with all pertinent Federal
entities (including the Department of Defense, the Department
of Health and Human Services, and the Centers for Medicare &
Medicaid Services), entities in the private sector, and other
nongovernmental entities in establishing access guidelines and
standards for quality as required by sections 1703B and 1703C
of this title.
(4) Not later than 270 days after the date of the enactment
of the Caring for our Veterans Act of 2017, the Secretary shall
submit to the appropriate committees of Congress a report
detailing the access guidelines and standards for quality
established under sections 1703B and 1703C of this title.
(5) Not later than three years after the date on which the
Secretary establishes access guidelines and standards for
quality under paragraph (1) and not less frequently than once
every three years thereafter, the Secretary shall--
(A) conduct a review of such guidelines and
standards; and
(B) submit to the appropriate committees of Congress
a report on the findings and any modification to the
access guidelines and standards for quality with
respect to the review conducted under subparagraph (A).
(6) The Secretary shall ensure health care providers
specified under subsection (c) are able to meet the applicable
access guidelines and standards of quality established by the
Secretary.
(i) Tiered Network.--(1) To promote the provision of high-
quality and high-value hospital care, medical services, and
extended care services under this section, the Secretary may
develop a tiered provider network of eligible providers based
on criteria established by the Secretary for purposes of this
section.
(2) In developing a tiered provider network of eligible
providers under paragraph (1), the Secretary shall not
prioritize providers in a tier over providers in any other tier
in a manner that limits the choice of a covered veteran in
selecting a health care provider specified in subsection (c)
for receipt of hospital care, medical services, or extended
care services under this section.
(j) Contracts To Establish Networks of Health Care
Providers.--(1) The Secretary shall enter into consolidated,
competitively bid contracts to establish networks of health
care providers specified in paragraphs (1) and (5) of
subsection (c) for purposes of providing sufficient access to
hospital care, medical services, or extended care services
under this section.
(2)(A) The Secretary shall, to the extent practicable,
ensure that covered veterans are able to make their own
appointments using advanced technology.
(B) To the extent practicable, the Secretary shall be
responsible for the scheduling of appointments for hospital
care, medical services, and extended care services under this
section.
(3)(A) The Secretary may terminate a contract with an
entity entered into under paragraph (1) at such time and upon
such notice to the entity as the Secretary may specify for
purposes of this section, if the Secretary notifies the
appropriate committees of Congress that, at a minimum--
(i) the entity--
(I) failed to comply substantially with the
provisions of the contract or with the
provisions of this section and the regulations
prescribed under this section;
(II) failed to comply with the access
guidelines or meet the standards of quality
established by the Secretary;
(III) is excluded from participation in a
Federal health care program (as defined in
section 1128B(f) of the Social Security Act (42
U.S.C. 1320a-7b(f))) under section 1128 or
1128A of the Social Security Act (42 U.S.C.
1320a-7 and 1320a-7a);
(IV) is identified as an excluded source on
the list maintained in the System for Award
Management, or any successor system; or
(V) has been convicted of a felony or other
serious offense under Federal or State law and
the continued participation of the entity would
be detrimental to the best interests of
veterans or the Department;
(ii) it is reasonable to terminate the contract based
on the health care needs of veterans; or
(iii) it is reasonable to terminate the contract
based on coverage provided by contracts or sharing
agreements entered into under authorities other than
this section.
(B) Nothing in subparagraph (A) may be construed to
restrict the authority of the Secretary to terminate a contract
entered into under paragraph (1) under any other provision of
law.
(4) Whenever the Secretary provides notice to an entity
that the entity is failing to meet contractual obligations
entered into under paragraph (1), the Secretary shall submit to
the Committee on Veterans' Affairs of the Senate and the
Committee on Veterans' Affairs of the House of Representatives
a report on such failure. Such report shall include the
following:
(A) An explanation of the reasons for providing such
notice.
(B) A description of the effect of such failure,
including with respect to cost, schedule, and
requirements.
(C) A description of the actions taken by the
Secretary to mitigate such failure.
(D) A description of the actions taken by the
contractor to address such failure.
(E) A description of any effect on the community
provider market for veterans in the affected area.
(5)(A) The Secretary shall instruct each entity awarded a
contract under paragraph (1) to recognize and accept, on an
interim basis, the credentials and qualifications of health
care providers who are authorized to furnished hospital care
and medical services to veterans under a community care program
of the Department in effect as of the day before the date of
the enactment of the Caring for our Veterans Act of 2017,
including under the Patient-Centered Community Care Program and
the Veterans Choice Program under section 101 of the Veterans
Access, Choice, and Accountability Act of 2014 (Public Law 113-
146; 38 U.S.C. 1701 note), as qualified providers under the
program established under this section.
(B) The interim acceptance period under subparagraph (A)
shall be determined by the Secretary based on the following
criteria:
(i) With respect to a health care provider, when the
current certification agreement for the health care
provider expires.
(ii) Whether the Department has enacted certification
and eligibility criteria and regulatory procedures by
which non-Department providers will be authorized under
this section.
(6) The Secretary shall establish through regulation a
system or systems for monitoring the quality of care provided
to covered veterans through a network under this subsection and
for assessing the quality of hospital care, medical services,
and extended care services furnished through such network
before the renewal of the contract for such network.
(k) Payment Rates for Care and Services.--(1) Except as
provided in paragraph (2), and to the extent practicable, the
rate paid for hospital care, medical services, or extended care
services under any provision in this title may not exceed the
rate paid by the United States to a provider of services (as
defined in section 1861(u) of the Social Security Act (42
U.S.C. 1395x(u))) or a supplier (as defined in section 1861(d)
of such Act (42 U.S.C. 1395x(d))) under the Medicare program
under title XI or title XVIII of the Social Security Act (42
U.S.C. 1301 et seq.) for the same care or services.
(2)(A) A higher rate than the rate paid by the United
States as described in paragraph (1) may be negotiated with
respect to the furnishing of care or services to a covered
veteran who resides in a highly rural area.
(B) In this paragraph, the term ``highly rural area'' means
an area located in a county that has fewer than seven
individuals residing in that county per square mile.
(3) With respect to furnishing care or services under this
section in Alaska, the Alaska Fee Schedule of the Department of
Veterans Affairs shall be followed, except for when another
payment agreement, including a contract or provider agreement,
is in effect.
(4) With respect to furnishing hospital care, medical
services, or extended care services under this section in a
State with an All-Payer Model Agreement under section
1814(b)(3) of the Social Security Act (42 U.S.C. 1395f(b)(3))
that became effective on or after January 1, 2014, the Medicare
payment rates under paragraph (2)(A) shall be calculated based
on the payment rates under such agreement.
(5) Notwithstanding paragraph (1), the Secretary may
incorporate, to the greatest extent practicable, the use of
value-based reimbursement models to promote the provision of
high-quality care.
(6) With respect to hospital care, medical services, or
extended care services for which there is not a rate paid under
the Medicare program as described in paragraph (1), the rate
paid for such care or services shall be determined by the
Secretary.
(l) Treatment of Other Health Care Plans.--(1) In any case
in which a covered veteran is furnished hospital care, medical
services, or extended care services under this section for a
non-service-connected disability described in subsection (a)(2)
of section 1729 of this title, the Secretary shall recover or
collect reasonable charges for such care or services from a
health care plan described in paragraph (2) in accordance with
such section.
(2) A health care plan described in this paragraph--
(A) is an insurance policy or contract, medical or
hospital service agreement, membership or subscription
contract, or similar arrangement not administered by
the Secretary, under which hospital care, medical
services, or extended care services for individuals are
provided or the expenses of such care or services are
paid; and
(B) does not include any such policy, contract,
agreement, or similar arrangement pursuant to title
XVIII or XIX of the Social Security Act (42 U.S.C. 1395
et seq.) or chapter 55 of title 10.
(m) Payment by Veteran.--A covered veteran shall not pay a
greater amount for receiving care or services under this
section than the amount the veteran would pay for receiving the
same or comparable care or services at a medical facility of
the Department or from a health care provider of the
Department.
(n) Monitoring of Care Provided.--(1)(A) Not later than 540
days after the date of the enactment of the Caring for our
Veterans Act of 2017, and not less frequently than annually
thereafter, the Secretary shall submit to appropriate
committees of Congress a review of the types and frequency of
care sought under subsection (d).
(B) The review submitted under subparagraph (A) shall
include an assessment of the following:
(i) The top 25 percent of types of care and services
most frequently provided under subsection (d) due to
the Department not offering such care and services.
(ii) The frequency such care and services were sought
by covered veterans under this section.
(iii) An analysis of the reasons the Department was
unable to provide such care and services.
(iv) Any steps the Department took to provide such
care and services at a medical facility of the
Department.
(v) The cost of such care and services.
(2) In monitoring the hospital care, medical services, and
extended care services furnished under this section, the
Secretary shall do the following:
(A) With respect to hospital care, medical services,
and extended care services furnished through provider
networks established under subsection (j)--
(i) compile data on the types of hospital
care, medical services, and extended care
services furnished through such networks and
how many patients used each type of care and
service;
(ii) identify gaps in hospital care, medical
services, or extended care services furnished
through such networks;
(iii) identify how such gaps may be fixed
through new contracts within such networks or
changes in the manner in which hospital care,
medical services, or extended care services are
furnished through such networks;
(iv) assess the total amounts spent by the
Department on hospital care, medical services,
and extended care services furnished through
such networks;
(v) assess the timeliness of the Department
in referring hospital care, medical services,
and extended care services to such networks;
and
(vi) assess the timeliness of such networks
in--
(I) accepting referrals; and
(II) scheduling and completing
appointments.
(B) Report the number of medical service lines the
Secretary has determined under subsection (e)(1) not to
be providing hospital care, medical services, or
extended care services that comply with the access
guidelines or meet the standards of quality established
by the Secretary.
(C) Assess the use of academic affiliates and centers
of excellence of the Department to furnish hospital
care, medical services, and extended care services to
covered veterans under this section.
(D) Assess the hospital care, medical services, and
extended care services furnished to covered veterans
under this section by medical facilities operated by
Federal agencies other than the Department.
(3) Not later than 540 days after the date of the enactment
of the Caring for our Veterans Act of 2017 and not less
frequently than once each year thereafter, the Secretary shall
submit to the Committee on Veterans' Affairs of the Senate and
the Committee on Veterans' Affairs of the House of
Representatives a report on the information gathered under
paragraph (2).
(o) Prohibition on Certain Limitations.--The Secretary
shall not limit the types of hospital care, medical services,
or extended care services covered veterans may receive under
this section if it is in the best interest of the veteran to
receive such hospital care, medical services, or extended care
services, as determined by the veteran and the veteran's health
care provider.
(p) Definitions.--In this section:
(1) The term ``appropriate committees of Congress''
means--
(A) the Committee on Veterans' Affairs and
the Committee on Appropriations of the Senate;
and
(B) the Committee on Veterans' Affairs and
the Committee on Appropriations of the House of
Representatives.
(2) The term ``medical service line'' means a clinic
within a Department medical center.
SEC. 1703A. AGREEMENTS WITH ELIGIBLE ENTITIES OR PROVIDERS;
CERTIFICATION PROCESSES
(a) Agreements Authorized.--(1)(A) When hospital care, a
medical service, or an extended care service required by a
veteran who is entitled to such care or service under this
chapter is not feasibly available to the veteran from a
facility of the Department or through a contract or sharing
agreement entered into pursuant to another provision of law,
the Secretary may furnish such care or service to such veteran
by entering into an agreement under this section with an
eligible entity or provider to provide such hospital care,
medical service, or extended care service.
(B) An agreement entered into under this section to provide
hospital care, a medical service, or an extended care service
shall be known as a ``Veterans Care Agreement''.
(C) For purposes of subparagraph (A), hospital care, a
medical service, or an extended care service may be considered
not feasibly available to a veteran from a facility of the
Department or through a contract or sharing agreement described
in such subparagraph when the Secretary determines the
veteran's medical condition, the travel involved, the nature of
the care or services required, or a combination of these
factors make the use of a facility of the Department or a
contract or sharing agreement described in such subparagraph
impracticable or inadvisable.
(D) A Veterans Care Agreement may be entered into by the
Secretary or any Department official authorized by the
Secretary.
(2)(A) Subject to subparagraph (B), the Secretary shall
review each Veterans Care Agreement of material size, as
determined by the Secretary or set forth in paragraph (3), for
hospital care, a medical service, or an extended care service
to determine whether it is feasible and advisable to provide
such care or service within a facility of the Department or by
contract or sharing agreement entered into pursuant to another
provision of law and, if so, take action to do so.
(B)(i) The Secretary shall review each Veterans Care
Agreement of material size that has been in effect for at least
six months within the first two years of its taking effect, and
not less frequently than once every four years thereafter.
(ii) If a Veterans Care Agreement has not been in effect
for at least six months by the date of the review required by
subparagraph (A), the agreement shall be reviewed during the
next cycle required by subparagraph (A), and such review shall
serve as its review within the first two years of its taking
effect for purposes of clause (i).
(3)(A) In fiscal year 2018 and in each fiscal year
thereafter, in addition to such other Veterans Care Agreements
as the Secretary may determine are of material size, a Veterans
Care Agreement for the purchase of extended care services that
exceeds $5,000,000 annually shall be considered of material
size.
(B) From time to time, the Secretary may publish a notice
in the Federal Register to adjust the dollar amount specified
in subparagraph (A) to account for changes in the cost of
health care based upon recognized health care market surveys
and other available data.
(b) Eligible Entities and Providers.--For purposes of this
section, an eligible entity or provider is--
(1) any provider of services that has enrolled and
entered into a provider agreement under section 1866(a)
of the Social Security Act (42 U.S.C. 1395cc(a)) and
any physician or other supplier who has enrolled and
entered into a participation agreement under section
1842(h) of such Act (42 U.S.C. 1395u(h));
(2) any provider participating under a State plan
under title XIX of such Act (42 U.S.C. 1396 et seq.);
or
(3) any entity or provider not described in paragraph
(1) or (2) of this subsection that the Secretary
determines to be eligible pursuant to the certification
process described in subsection (c).
(c) Eligible Entity or Provider Certification Process.--The
Secretary shall establish by regulation a process for the
certification of eligible entities or providers or
recertification of eligible entities or providers under this
section. Such a process shall, at a minimum--
(1) establish deadlines for actions on applications
for certification;
(2) set forth standards for an approval or denial of
certification, duration of certification, revocation of
an eligible entity or provider's certification, and
recertification of eligible entities or providers;
(3) require the denial of certification if the
Secretary determines the eligible entity or provider is
excluded from participation in a Federal health care
program under section 1128 or section 1128A of the
Social Security Act (42 U.S.C. 1320a-7 or 1320a-7a) or
is currently identified as an excluded source on the
System for Award Management Exclusions list described
in part 9 of title 48, Code of Federal Regulations, and
part 180 of title 2 of such Code, or successor
regulations;
(4) establish procedures for screening eligible
entities or providers according to the risk of fraud,
waste, and abuse that are similar to the standards
under section 1866(j)(2)(B) of the Social Security Act
(42 U.S.C. 1395cc(j)(2)(B)) and section 9.104 of title
48, Code of Federal Regulations, or successor
regulations; and
(5) incorporate and apply the restrictions and
penalties set forth in chapter 21 of title 41 and treat
this section as a procurement program only for purposes
of applying such provisions.
(d) Rates.--To the extent practicable, the rates paid by
the Secretary for hospital care, medical services, and extended
care services provided under a Veterans Care Agreement shall be
in accordance with the rates paid by the United States under
the Medicare program.
(e) Terms of Veterans Care Agreements.--(1) Pursuant to
regulations promulgated under subsection (k), the Secretary may
define the requirements for providers and entities entering
into agreements under this section based upon such factors as
the number of patients receiving care or services, the number
of employees employed by the entity or provider furnishing such
care or services, the amount paid by the Secretary to the
provider or entity, or other factors as determined by the
Secretary.
(2) To furnish hospital care, medical services, or extended
care services under this section, an eligible entity or
provider shall agree--
(A) to accept payment at the rates established in
regulations prescribed under this section;
(B) that payment by the Secretary under this section
on behalf of a veteran to a provider of services or
care shall, unless rejected and refunded by the
provider within 30 days of receipt, constitute payment
in full and extinguish any liability on the part of the
veteran for the treatment or care provided, and no
provision of a contract, agreement, or assignment to
the contrary shall operate to modify, limit, or negate
this requirement;
(C) to provide only the care and services authorized
by the Department under this section and to obtain the
prior written consent of the Department to furnish care
or services outside the scope of such authorization;
(D) to bill the Department in accordance with the
methodology outlined in regulations prescribed under
this section;
(E) to not seek to recover or collect from a health
plan contract or third party, as those terms are
defined in section 1729 of this title, for any care or
service that is furnished or paid for by the
Department;
(F) to provide medical records to the Department in
the time frame and format specified by the Department;
and
(G) to meet such other terms and conditions,
including quality of care assurance standards, as the
Secretary may specify in regulation.
(f) Discontinuation or Nonrenewal of a Veterans Care
Agreement.--(1) An eligible entity or provider may discontinue
a Veterans Care Agreement at such time and upon such notice to
the Secretary as may be provided in regulations prescribed
under this section.
(2) The Secretary may discontinue a Veterans Care Agreement
with an eligible entity or provider at such time and upon such
reasonable notice to the eligible entity or provider as may be
specified in regulations prescribed under this section, if an
official designated by the Secretary--
(A) has determined that the eligible entity or
provider failed to comply substantially with the
provisions of the Veterans Care Agreement, or with the
provisions of this section or regulations prescribed
under this section;
(B) has determined the eligible entity or provider is
excluded from participation in a Federal health care
program under section 1128 or section 1128A of the
Social Security Act (42 U.S.C. 1320a-7 or 1320a-7a) or
is identified on the System for Award Management
Exclusions list as provided in part 9 of title 48, Code
of Federal Regulations, and part 180 of title 2 of such
Code, or successor regulations;
(C) has ascertained that the eligible entity or
provider has been convicted of a felony or other
serious offense under Federal or State law and
determines the eligible entity or provider's continued
participation would be detrimental to the best
interests of veterans or the Department; or
(D) has determined that it is reasonable to terminate
the agreement based on the health care needs of a
veteran.
(g) Quality of Care.--The Secretary shall establish through
regulation a system or systems for monitoring the quality of
care provided to veterans through Veterans Care Agreements and
for assessing the quality of hospital care, medical services,
and extended care services furnished by eligible entities and
providers before the renewal of Veterans Care Agreements.
(h) Disputes.--(1) The Secretary shall promulgate
administrative procedures for eligible entities and providers
to present all disputes arising under or related to Veterans
Care Agreements.
(2) Such procedures constitute the eligible entities' and
providers' exhaustive and exclusive administrative remedies.
(3) Eligible entities or providers must first exhaust such
administrative procedures before seeking any judicial review
under section 1346 of title 28 (known as the ``Tucker Act'').
(4) Disputes under this section must pertain to either the
scope of authorization under the Veterans Care Agreement or
claims for payment subject to the Veterans Care Agreement and
are not claims for the purposes of such laws that would
otherwise require application of sections 7101 through 7109 of
title 41, United States Code.
(i) Applicability of Other Provisions of Law.--(1) A
Veterans Care Agreement may be authorized by the Secretary or
any Department official authorized by the Secretary, and such
action shall not be treated as--
(A) an award for the purposes of such laws that would
otherwise require the use of competitive procedures for
the furnishing of care and services; or
(B) a Federal contract for the acquisition of goods
or services for purposes of any provision of Federal
law governing Federal contracts for the acquisition of
goods or services.
(2)(A) Except as provided in subparagraph (B), and unless
otherwise provided in this section or regulations prescribed
pursuant to this section, an eligible entity or provider that
enters into an agreement under this section is not subject to,
in the carrying out of the agreement, any law to which
providers of services and suppliers under the Medicare program
under title XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.) are not subject.
(B) An eligible entity or provider that enters into an
agreement under this section is subject to--
(i) all laws regarding integrity, ethics, or fraud,
or that subject a person to civil or criminal
penalties; and
(ii) all laws that protect against employment
discrimination or that otherwise ensure equal
employment opportunities.
(3) Notwithstanding paragraph (2)(B)(i), an eligible entity
or provider that enters into an agreement under this section
shall not be treated as a Federal contractor or subcontractor
for purposes of chapter 67 of title 41 (commonly known as the
``McNamara-O'Hara Service Contract Act of 1965'').
(j) Parity of Treatment.--Eligibility for hospital care,
medical services, and extended care services furnished to any
veteran pursuant to a Veterans Care Agreement shall be subject
to the same terms as though provided in a facility of the
Department, and provisions of this chapter applicable to
veterans receiving such care and services in a facility of the
Department shall apply to veterans treated under this section.
(k) Rulemaking.--The Secretary shall promulgate regulations
to carry out this section.
SEC. 1703B. ACCESS GUIDELINES
The Secretary shall consult with all pertinent Federal
entities to examine health care access measurements and
establish localized benchmarking guidelines that can inform
provider and veteran clinical decisionmaking. The Secretary
shall establish such guidelines for all hospital care, medical
services, and extended care services furnished or otherwise
made available under laws administered by the Secretary,
including through non-Department health care providers.
SEC. 1703C. STANDARDS FOR QUALITY
(a) In General.--(1) The Secretary shall establish
standards for quality, in coordination or consultation with
entities pursuant to section 1703(h)(3) of this title,
regarding hospital care, medical services, and extended care
services furnished by the Department pursuant to this title,
including through non-Department health care providers pursuant
to section 1703 of this title.
(2) In establishing standards for quality under paragraph
(1), the Secretary shall consider existing health quality
measures that are applied to public and privately sponsored
health care systems with the purpose of providing covered
veterans relevant comparative information to make informed
decisions regarding their health care.
(3) The Secretary shall collect and consider data for
purposes of establishing the standards under paragraph (1).
Such data collection shall include--
(A) after consultation with veterans service
organizations and other key stakeholders on survey
development or modification of an existing survey, a
survey of veterans who have used hospital care, medical
services, or extended care services furnished by the
Veterans Health Administration during the most recent
two-year period to assess the satisfaction of the
veterans with service and quality of care; and
(B) datasets that include, at a minimum, elements
relating to the following:
(i) Timely care.
(ii) Effective care.
(iii) Safety, including, at a minimum,
complications, readmissions, and deaths.
(iv) Efficiency.
(b) Publication and Consideration of Public Comments.--(1)
Not later than one year after the date on which the Secretary
establishes standards for quality under subsection (a), the
Secretary shall publish the quality rating of medical
facilities of the Department in the publicly available Hospital
Compare website through the Centers for Medicare & Medicaid
Services for the purpose of providing veterans with information
that allows them to compare performance measure information
among Department and non-Department health care providers.
(2) Not later than two years after the date on which the
Secretary establishes standards for quality under subsection
(a), the Secretary shall consider and solicit public comment on
potential changes to the measures used in such standards to
ensure that they include the most up-to-date and applicable
industry measures for veterans.
SEC. 1703D. PROMPT PAYMENT STANDARD
(a) In General.--(1) Notwithstanding any other provision of
this title or of any other provision of law, the Secretary
shall pay for hospital care, medical services, or extended care
services furnished by health care entities or providers under
this chapter within 45 calendar days upon receipt of a clean
paper claim or 30 calendar days upon receipt of a clean
electronic claim.
(2) If a claim is denied, the Secretary shall, within 45
calendar days of denial for a paper claim and 30 calendar days
of denial for an electronic claim, notify the health care
entity or provider of the reason for denying the claim and
what, if any, additional information is required to process the
claim.
(3) Upon the receipt of the additional information, the
Secretary shall ensure that the claim is paid, denied, or
otherwise adjudicated within 30 calendar days from the receipt
of the requested information.
(4) This section shall only apply to payments made on an
invoice basis and shall not apply to capitation or other forms
of periodic payment to entities or providers.
(b) Submittal of Claims by Health Care Entities and
Providers.--A health care entity or provider that furnishes
hospital care, a medical service, or an extended care service
under this chapter shall submit to the Secretary a claim for
payment for furnishing the hospital care, medical service, or
extended care service not later than 180 days after the date on
which the entity or provider furnished the hospital care,
medical service, or extended care service.
(c) Fraudulent Claims.--(1) Sections 3729 through 3733 of
title 31 shall apply to fraudulent claims for payment submitted
to the Secretary by a health care entity or provider under this
chapter.
(2) Pursuant to regulations prescribed by the Secretary,
the Secretary shall bar a health care entity or provider from
furnishing hospital care, medical services, and extended care
services under this chapter when the Secretary determines the
entity or provider has submitted to the Secretary fraudulent
health care claims for payment by the Secretary.
(d) Overdue Claims.--(1) Any claim that has not been denied
with notice, made pending with notice, or paid to the health
care entity or provider by the Secretary shall be overdue if
the notice or payment is not received by the entity provider
within the time periods specified in subsection (a).
(2)(A) If a claim is overdue under this subsection, the
Secretary may, under the requirements established by subsection
(a) and consistent with the provisions of chapter 39 of title
31 (commonly referred to as the ``Prompt Payment Act''),
require that interest be paid on clean claims.
(B) Interest paid under subparagraph (A) shall be computed
at the rate of interest established by the Secretary of the
Treasury under section 3902 of title 31 and published in the
Federal Register.
(3) Not less frequently than annually, the Secretary shall
submit to Congress a report on payment of overdue claims under
this subsection, disaggregated by paper and electronic claims,
that includes the following:
(A) The amount paid in overdue claims described in
this subsection, disaggregated by the amount of the
overdue claim and the amount of interest paid on such
overdue claim.
(B) The number of such overdue claims and the average
number of days late each claim was paid, disaggregated
by facility of the Department and Veterans Integrated
Service Network region.
(e) Overpayment.--(1) The Secretary shall deduct the amount
of any overpayment from payments due a health care entity or
provider under this chapter.
(2) Deductions may not be made under this subsection unless
the Secretary has made reasonable efforts to notify a health
care entity or provider of the right to dispute the existence
or amount of such indebtedness and the right to request a
compromise of such indebtedness.
(3) The Secretary shall make a determination with respect
to any such dispute or request prior to deducting any
overpayment unless the time required to make such a
determination before making any deductions would jeopardize the
Secretary's ability to recover the full amount of such
indebtedness.
(f) Information and Documentation Required.--(1) The
Secretary shall provide to all health care entities and
providers participating in a program to furnish hospital care,
medical services, or extended care services under this chapter
a list of information and documentation that is required to
establish a clean claim under this section.
(2) The Secretary shall consult with entities in the health
care industry, in the public and private sector, to determine
the information and documentation to include in the list under
paragraph (1).
(3) If the Secretary modifies the information and
documentation included in the list under paragraph (1), the
Secretary shall notify all health care entities and providers
described in paragraph (1) not later than 30 days before such
modifications take effect.
(g) Processing of Claims.--In processing a claim for
compensation for hospital care, medical services, or extended
care services furnished by a health care entity or provider
under this chapter, the Secretary shall act through--
(1) a non-Department entity that is under contract or
agreement for the program established under section
1703(a) of this title; or
(2) a non-Department entity that specializes in such
processing for other Federal agency health care
systems.
(h) Report on Encounter Data System.--(1) Not later than 90
days after the date of the enactment of the Caring for our
Veterans Act of 2017, the Secretary shall submit to the
appropriate committees of Congress a report on the feasibility
and advisability of adopting a funding mechanism similar to
what is utilized by other Federal agencies to allow a
contracted entity to act as a fiscal intermediary for the
Federal Government to distribute, or pass through, Federal
Government funds for certain non-underwritten hospital care,
medical services, or extended care services.
(2) The Secretary may coordinate with the Department of
Defense, the Department of Health and Human Services, and the
Department of the Treasury in developing the report required by
paragraph (1).
(i) Definitions.--In this section:
(1) The term ``appropriate committees of Congress''
means--
(A) the Committee on Veterans' Affairs and
the Committee on Appropriations of the Senate;
and
(B) the Committee on Veterans' Affairs and
the Committee on Appropriations of the House of
Representatives.
(2) The term ``clean electronic claim'' means the
transmission of data for purposes of payment of covered
health care expenses that is submitted to the Secretary
which contains substantially all of the required data
elements necessary for accurate adjudication, without
obtaining additional information from the entity or
provider that furnished the care or service, submitted
in such format as prescribed by the Secretary in
regulations for the purpose of paying claims for care
or services.
(3) The term ``clean paper claim'' means a paper
claim for payment of covered health care expenses that
is submitted to the Secretary which contains
substantially all of the required data elements
necessary for accurate adjudication, without obtaining
additional information from the entity or provider that
furnished the care or service, submitted in such format
as prescribed by the Secretary in regulations for the
purpose of paying claims for care or services.
(4) The term ``fraudulent claims'' means the
intentional and deliberate misrepresentation of a
material fact or facts by a health care entity or
provider made to induce the Secretary to pay a claim
that was not legally payable to that provider. This
term, as used in this section, shall not include a good
faith interpretation by a health care entity or
provider of utilization, medical necessity, coding, and
billing requirements of the Secretary.
(5) The term ``health care entity or provider''
includes any non-Department health care entity or
provider, but does not include any Federal health care
entity or provider.
Subchapter II. Hospital, Nursing Home, or Domiciliary Care and Medical
Treatment
SEC. 1712. DENTAL CARE; DRUGS AND MEDICINES FOR CERTAIN DISABLED
VETERANS; VACCINES
(a)(1) * * *
* * * * * * *
(3) The total amount which the Secretary may expend for
furnishing, during any twelve-month period, outpatient dental
services, treatment, or related dental appliances to a veteran
under this section through private facilities for which the
Secretary has contracted [under clause (1), (2), or (5) of
section 1703(a) of this title] or entered an agreement may not
exceed $1,000 unless the Secretary determines, prior to the
furnishing of such services, treatment, or appliances and based
on an examination of the veteran by a dentist employed by the
Department (or, in an area where no such dentist is available,
by a dentist conducting such examination under a contract or
fee arrangement), that the furnishing of such services,
treatment, or appliances at such cost is reasonably necessary.
(4)(A) Except as provided in subparagraph (B) of this
paragraph, in any year in which the President's Budget for the
fiscal year beginning October 1 of such year includes an amount
for expenditures for contract dental care [under the provisions
of this subsection and section 1703 of this title] during such
fiscal year * * *
* * * * * * *
SEC. 1712A. ELIGIBILITY FOR READJUSTMENT COUNSELING AND RELATED MENTAL
HEALTH SERVICES
(a)(1)(A) * * *
(e)(1) In furnishing counseling and related mental health
services under subsections (a) and (b) of this section, the
Secretary shall have available the same authority to enter into
contracts or agreementswith private facilities that is
available to the Secretary [(under sections 1703(a)(2) and
1710(a)(1)(B) of this title)] in furnishing medical services to
veterans suffering from total service-connected disabilities.
* * * * * * *
SEC. 1720G. ASSISTANCE AND SUPPORT SERVICES FOR CAREGIVERS
(a) Program of Comprehensive Assistance for Family
Caregivers.--(1)(A) * * *
(2) * * *
* * * * * * *
[(B) has a serious injury (including traumatic brain
injury, psychological trauma, or other mental disorder)
incurred or aggravated in the line of duty in the
active military, naval, or air service on or after
September 11, 2001; and]
(B) for assistance provided under this subsection--
(i) before the date on which the Secretary
submits to Congress a certification that the
Department has fully implemented the
information technology system required by
section 302(a) of the Caring for our Veterans
Act of 2017, has a serious injury (including
traumatic brain injury, psychological trauma,
or other mental disorder) incurred or
aggravated in the line of duty in the active
military, naval, or air service on or after
September 11, 2001;
(ii) during the two-year period beginning on
the date on which the Secretary submitted to
Congress the certification described in clause
(i), has a serious injury (including traumatic
brain injury, psychological trauma, or other
mental disorder) incurred or aggravated in the
line of duty in the active military, naval, or
air service--
(I) on or before May 7, 1975; or
(II) on or after September 11, 2001;
or
(iii) after the date that is two years after
the date on which the Secretary submits to
Congress the certification described in clause
(i), has a serious injury (including traumatic
brain injury, psychological trauma, or other
mental disorder) incurred or aggravated in the
line of duty in the active military, naval, or
air service; and
(C) is in need of personal care services because of--
(i) * * *
(ii) a need for supervision or protection
based on symptoms or residuals of neurological
or other impairment or injury[; or] ;
(iii) a need for regular or extensive
instruction or supervision without which the
ability of the veteran to function in daily
life would be seriously impaired; or
(iv) [(iii)] such other matters as the
Secretary considers appropriate.
(3)(A) * * *
* * * * * * *
(ii) * * *
* * * * * * *
(IV) medical care under section 1781 of this
title[; and] ;
(V) a monthly personal caregiver stipend[.] ;
and
(VI) through the use of contracts with, or
the provision of grants to, public or private
entities--
(aa) financial planning services
relating to the needs of injured
veterans and their caregivers; and
(bb) legal services, including legal
advice and consultation, relating to
the needs of injured veterans and their
caregivers.
* * * * * * *
(C)(i) * * *
* * * * * * *
(iii) In determining the amount and degree of personal care
services provided under clause (i) with respect to an eligible
veteran whose need for personal care services is based in whole
or in part on a need for supervision or protection under
paragraph (2)(C)(ii) or regular instruction or supervision
under paragraph (2)(C)(iii), the Secretary shall take into
account the following:
(I) The assessment by the family caregiver of the
needs and limitations of the veteran.
(II) The extent to which the veteran can function
safely and independently in the absence of such
supervision, protection, or instruction.
(III) The amount of time required for the family
caregiver to provide such supervision, protection, or
instruction to the veteran.
(iv) [(iii)] If personal care services are not available
from a commercial home health entity in the geographic area of
an eligible veteran, the amount of the monthly personal
caregiver stipend payable under the schedule required by clause
(i) with respect to the eligible veteran shall be determined by
taking into consideration the costs of commercial providers of
personal care services in providing personal care services in
geographic areas other than the geographic area of the eligible
veteran with similar costs of living.
(D) In providing instruction, preparation, and training
under subparagraph (A)(i)(I) and technical support under
subparagraph (A)(i)(II) to each family caregiver who is
approved as a provider of personal care services for an
eligible veteran under paragraph (6), the Secretary shall
periodically evaluate the needs of the eligible veteran and the
skills of the family caregiver of such veteran to determine if
additional instruction, preparation, training, or technical
support under those subparagraphs is necessary.
(4) * * *
(5) For each application submitted jointly by an eligible
veteran and family member, the Secretary shall evaluate (in
collaboration with the primary care team for the eligible
veteran to the maximum extent practicable)--
* * * * * * *
(11)(A) In providing assistance under this subsection to
family caregivers of eligible veterans, the Secretary may enter
into contracts, provider agreements, and memoranda of
understanding with Federal agencies, States, and private,
nonprofit, and other entities to provide such assistance to
such family caregivers.
(B) The Secretary may provide assistance under this
paragraph only if such assistance is reasonably accessible to
the family caregiver and is substantially equivalent or better
in quality to similar services provided by the Department.
(C) The Secretary may provide fair compensation to Federal
agencies, States, and other entities that provide assistance
under this paragraph.
* * * * * * *
(d) Definitions.--In this section:
* * * * * * *
(4) * * *
(A) Assistance with one or more [independent]
activities of daily living.
(B) Supervision or protection based on
symptoms or residuals of neurological or other
impairment or injury.
(C) Regular or extensive instruction or
supervision without which the ability of the
veteran to function in daily life would be
seriously impaired.
(D) [(B)] Any other non-institutional
extended care (as such term is used in section
1701(6)(E) of this title).
* * * * * * *
Subchapter III. Miscellaneous Provisions Relating to Hospital and
Nursing Home Care and Medical Treatment of Veterans
* * * * * * *
SEC. 1725A. ACCESS TO WALK-IN CARE
(a) Procedures To Ensure Access to Walk-in Care.--The
Secretary shall develop procedures to ensure that eligible
veterans are able to access walk-in care from qualifying non-
Department entities or providers.
(b) Eligible Veterans.--For purposes of this section, an
eligible veteran is any individual who--
(1) is enrolled in the health care system established
under section 1705(a) of this title; and
(2) has received care under this chapter within the
24-month period preceding the furnishing of walk-in
care under this section.
(c) Qualifying Non-Department Entities or Providers.--For
purposes of this section, a qualifying non-Department entity or
provider is a non-Department entity or provider that has
entered into a contract or other agreement with the Secretary
to furnish services under this section.
(d) Federally-qualified Health Centers.--Whenever
practicable, the Secretary may use a Federally-qualified health
center (as defined in section 1905(l)(2)(B) of the Social
Security Act (42 U.S.C. 1396d(l)(2)(B))) to carry out this
section.
(e) Continuity of Care.--The Secretary shall ensure
continuity of care for those veterans who receive walk-in care
services under this section, including through the
establishment of a mechanism to receive medical records from
walk-in care providers and provide pertinent patient medical
records to providers of walk-in care.
(f) Copayments.--(1)(A) The Secretary shall require all
eligible veterans to pay the United States a copayment for each
episode of hospital care and medical service provided under
this section if otherwise required to pay a copayment under
this title.
(B) Those not required to pay a copayment under this title
may access walk-in care without a copayment for the first two
visits in a calendar year. For any additional visits, a
copayment at an amount determined by the Secretary shall be
paid.
(C) For those veterans required to pay a copayment under
title 38, they are required to pay their regular copayment for
their first two walk-in care visits in a calendar year. For any
additional visits, a higher copayment at an amount determined
by the Secretary shall be paid.
(2) After the first two episodes of care furnished to a
veteran under this section, the Secretary may adjust the
copayment required of the veteran under this subsection based
upon the priority group of enrollment of the veteran, the
number of episodes of care furnished to the veteran during a
year, and other factors the Secretary considers appropriate
under this section.
(3) The amount or amounts of the copayments required under
this subsection shall be prescribed by the Secretary by rule.
(4) Section 8153(c) of this title shall not apply to this
subsection.
(g) Regulations.--Not later than one year after the date of
the enactment of the Caring for our Veterans Act of 2017, the
Secretary shall promulgate regulations to carry out this
section.
(h) Walk-in Care Defined.--In this section, the term
``walk-in care'' means non-emergent care provided by a
qualifying non-Department entity or provider that furnishes
episodic care and not longitudinal management of conditions and
is otherwise defined through regulations the Secretary shall
promulgate.
SEC. 1729. RECOVERY BY THE UNITED STATES OF THE COST OF CERTAIN CARE
AND SERVICES
(a)[(1) Subject to the provisions of this section, in any
case in which a veteran is furnished care or services under
this chapter for a non-service-connected disability described
in paragraph (2) of this subsection, the United States has the
right to recover or collect reasonable charges for such care or
services (as determined by the Secretary) from a third party to
the extent that the veteran (or the provider of the care or
services) would be eligible to receive payment for such care or
services from such third party if the care or services had not
been furnished by a department or agency of the United States]
(1) Subject to the provisions of this section, in any case in
which the United States is required by law to furnish or pay
for care or services under this chapter for a non-service-
connected disability described in paragraph (2) of this
subsection, the United States has the right to recover or
collect from a third party the reasonable charges of care or
services so furnished or paid for to the extent that the
recipient or provider of the care or services would be eligible
to receive payment for such care or services from such third
party if the care or services had not been furnished or paid
for by a department or agency of the United States..
(2) Paragraph (1) of this subsection applies to a non-
service-connected disability--
(A) that is incurred incident to [the veteran's] the
individual's employment and that is covered under a
workers' compensation law or plan that provides for
payment for the cost of health care and services
provided to [the veteran] the individual by reason of
the disability;
* * * * * * *
(D) [that is incurred by a veteran-] that is incurred
by an individual who is entitled to care (or payment of
the expenses of care) under a health-plan contract.
* * * * * * *
(3) In the case of a health-plan contract that contains a
requirement for payment of a deductible or copayment by [the
veteran] the individual--
(A) [the veteran's] the individual's not having paid
such deductible or copayment with respect to care or
services furnished under this chapter shall not
preclude recovery or collection under this section; and
* * * * * * *
(b)(1) As to the right provided in subsection (a) of this
section, the United States shall be subrogated to any right or
claim that [the veteran] the individual (or [the veteran's] the
individual's personal representative, successor, dependents, or
survivors) may have against a third party.
(2)(A) In order to enforce any right or claim to which the
United States is subrogated under paragraph (1) of this
subsection, the United States may intervene or join in any
action or proceeding brought by [the veteran] the individual
(or [the veteran's] the individual's personal representative,
successor, dependents, or survivors) against a third party.
(B) The United States may institute and prosecute legal
proceedings against the third party if--
(i) an action or proceeding described in subparagraph
(A) of this paragraph is not begun within 180 days
after the first day on which care or services for which
recovery is sought are furnished to [the veteran] the
individual by the Secretary under this chapter;
(ii) the United States has sent written notice by
certified mail to [the veteran] the individual at [the
veteran's] the individual's last-known address (or to
[the veteran's] the individual's personal
representative or successor) of the intention of the
United States to institute such legal proceedings; and
* * * * * * *
(e) [A veteran] An individual eligible for care or services
under this chapter--
* * * * * * *
(h)(1) Subject to paragraph (3) of this subsection, the
Secretary shall make available medical records of [a veteran]
an individual described in paragraph (2) of this subsection for
inspection and review by representatives of the third party
concerned for the sole purposes of permitting the third party
to verify--
(A) that the care or services for which recovery or
collection is sought were furnished to [the veteran]
the individual; and
(B) that the provision of such care or services to
[the veteran] the individual meets criteria generally
applicable under the health-plan contract involved.
(2) [A veteran] An individual described in this paragraph
is [a veteran] an individual who is a beneficiary of a health-
plan contract under which recovery or collection is sought
under this section from the third party concerned for the cost
of the care or services furnished to [the veteran] the
individual.
* * * * * * *
SEC. 1730B. LICENSURE OF HEALTH CARE PROFESSIONALS PROVIDING TREATMENT
VIA TELEMEDICINE
(a) In General.--Notwithstanding any provision of law
regarding the licensure of health care professionals, a covered
health care professional may practice the health care
profession of the health care professional at any location in
any State, regardless of where the covered health care
professional or the patient is located, if the covered health
care professional is using telemedicine to provide treatment to
an individual under this chapter.
(b) Covered Health Care Professionals.--For purposes of
this section, a covered health care professional is any health
care professional who--
(1) is an employee of the Department appointed under
the authority under section 7306, 7401, 7405, 7406, or
7408 of this title or title 5;
(2) is authorized by the Secretary to provide health
care under this chapter;
(3) is required to adhere to all standards of quality
relating to the provision of medicine in accordance
with applicable policies of the Department; and
(4) has an active, current, full, and unrestricted
license, registration, or certification in a State to
practice the health care profession of the health care
professional.
(c) Property of Federal Government.--Subsection (a) shall
apply to a covered health care professional providing treatment
to a patient regardless of whether the covered health care
professional or patient is located in a facility owned by the
Federal Government during such treatment.
(d) Relation to State Law.--(1) The provisions of this
section shall supersede any provisions of the law of any State
to the extent that such provision of State law are inconsistent
with this section.
(2) No State shall deny or revoke the license,
registration, or certification of a covered health care
professional who otherwise meets the qualifications of the
State for holding the license, registration, or certification
on the basis that the covered health care professional has
engaged or intends to engage in activity covered by subsection
(a).
(e) Rule of Construction.--Nothing in this section may be
construed to remove, limit, or otherwise affect any obligation
of a covered health care professional under the Controlled
Substances Act (21 U.S.C. 801 et seq.).
* * * * * * *
Subchapter V. Payments to State Homes
* * * * * * *
SEC. 1745. NURSING HOME CARE AND MEDICATIONS FOR VETERANS WITH SERVICE-
CONNECTED DISABILITIES
(a)(1) The Secretary shall enter into a contract [(or
agreement under section 1720(c)(1) of this title)] (or an
agreement) with each State home for payment by the Secretary
for nursing home care provided in the home, in any case in
which such care is provided to any veteran as follows:
* * * * * * *
(4)(A) An agreement under this section may be authorized by
the Secretary or any Department official authorized by the
Secretary, and any such action is not an award for purposes of
such laws that would otherwise require the use of competitive
procedures for the furnishing of hospital care, medical
services, and extended care services.
(B)(i) Except as provided in clause (ii), and unless
otherwise provided in this section or regulations prescribed
pursuant to this section, a State home that enters into an
agreement under this section is not subject to, in the carrying
out of the agreement, any provision of law to which providers
of services and suppliers under the Medicare program under
title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.)
are not subject.
(ii) A State home that enters into an agreement under this
section is subject to--
(I) all provisions of law regarding integrity,
ethics, or fraud, or that subject a person to civil or
criminal penalties; and
(II) all provisions of law that protect against
employment discrimination or that otherwise ensure
equal employment opportunities.
(iii) Notwithstanding subparagraph (B)(ii)(I), a State home
that enters into an agreement under this section may not be
treated as a Federal contractor or subcontractor for purposes
of chapter 67 of title 41 (known as the ``McNamara-O'Hara
Service Contract Act of 1965'').
* * * * * * *
Subchapter VIII. Health Care of Persons Other Than Veterans
* * * * * * *
SEC. 1788. TRANSPLANT PROCEDURES WITH LIVE DONORS AND RELATED SERVICES
(a) In General.--Subject to subsections (b) and (c), in a
case in which a veteran is eligible for a transplant procedure
from the Department, the Secretary may provide for an operation
on a live donor to carry out such procedure for such veteran,
notwithstanding that the live donor may not be eligible for
health care from the Department.
(b) Other Services.--Subject to the availability of
appropriations for such purpose, the Secretary shall furnish to
a live donor any care or services before and after conducting
the transplant procedure under subsection (a) that may be
required in connection with such procedure.
(c) Use of Non-Department Facilities.--In carrying out this
section, the Secretary may provide for the operation described
in subsection (a) on a live donor and furnish to the live donor
the care and services described in subsection (b) at a non-
Department facility pursuant to an agreement entered into by
the Secretary under this chapter. The live donor shall be
deemed to be an individual eligible for hospital care and
medical services at a non-Department facility pursuant to such
an agreement solely for the purposes of receiving such
operation, care, and services at the non-Department facility.
* * * * * * *
Chapter 23. Burial Benefits
* * * * * * *
SEC. 2303. DEATH IN DEPARTMENT FACILITY; PLOT ALLOWANCE
(a)(1) * * *
* * * * * * *
(2) * * *
(A) * * *
(B) an institution at which the deceased veteran was,
at the time of death, receiving--
(i) hospital care in accordance [with section
1703] with sections 1703A, 8111, and 8153 of
this title;
* * * * * * *
Part V. Boards, Administrations, and Services
* * * * * * *
Chapter 73. Veterans Health Administration-Organization and Functions
* * * * * * *
Subchapter I. Organization
* * * * * * *
SEC. 7309. READJUSTMENT COUNSELING SERVICE
(a) * * *
(b) * * *
(2) * * *
* * * * * * *
(B) have at least three years of experience
providing direct counseling services or
outreach services [in the Readjustment
Counseling Service];
(C) have at least three years of experience
administrating direct counseling services or
outreach services [in the Readjustment
Counseling Service];
* * * * * * *
Subchapter III. Protection of Patient Rights
* * * * * * *
SEC. 7332. CONFIDENTIALITY OF CERTAIN MEDICAL RECORDS
* * * * * * *
(b)(1) * * *
(2) Whether or not any patient or subject, with respect to
whom any given record referred to in subsection (a) is
maintained, gives written consent, the content of such record
may be disclosed by the Secretary as follows:
* * * * * * *
[(H)(i) To a non-Department entity (including private
entities and other Federal agencies) that provides
hospital care or medical services to veterans as
authorized by the Secretary.
[(ii) An entity to which a record is disclosed under
this subparagraph may not redisclose or use such record
for a purpose other than that for which the disclosure
was made.]
(H)(i) To a non-Department entity (including private
entities and other Federal agencies) for purposes of
providing health care, including hospital care, medical
services, and extended care services, to patients.
(ii) An entity to which a record is disclosed under
this subparagraph may not disclose or use such record
for a purpose other than that for which the disclosure
was made.
(I) To a third party in order to recover or collect
reasonable charges for care furnished to, or paid on
behalf of, a patient in connection with a non-service
connected disability as permitted by section 1729 of
this title or for a condition for which recovery is
authorized or with respect to which the United States
is deemed to be a third party beneficiary under the Act
entitled ``An Act to provide for the recovery from
tortiously liable third persons of the cost of hospital
and medical care and treatment furnished by the United
States'' (Public Law 87-693; 42 U.S.C. 2651 et seq.;
commonly known as the ``Federal Medical Care Recovery
Act'').
* * * * * * *
Chapter 74. Veterans Health Administration-Personnel
SUBCHAPTER I. APPOINTMENTS
Sec.
* * * * * * *
[7411.Full-time board-certified physicians and dentists:
reimbursement of continuing professional education
expenses.]
7411. Reimbursement of continuing professional education
expenses.
7412. Annual determination of staffing shortages; recruitment and
appointment for needed occupations.
7413. Treatment of podiatrists; clinical oversight standards.
* * * * * * *
Subchapter I. Appointments
SEC. 7401. APPOINTMENTS IN VETERANS HEALTH ADMINISTRATION
* * * * * * *
(1) Physicians, dentists, podiatrists, chiropractors,
optometrists, registered nurses, physician assistants,
certified clinical perfusionists, and expanded-function
dental auxiliaries.
* * * * * * *
SEC. 7404. GRADES AND PAY SCALES
(a)(1)(A) * * *
* * * * * * *
(b) The grades for positions provided for in paragraph (1)
of section 7401 of this title shall be as follows. The annual
ranges of rates of basic pay for those grades shall be
prescribed from time to time by Executive order as authorized
by chapter 53 of title 5 or as otherwise authorized by law:
[PHYSICIAN AND DENTIST SCHEDULE] PHYSICIAN AND SURGEON (MD/DO),
PODIATRIC SURGEON (DPM), AND DENTIST AND ORAL SURGEON (DDS, DMD)
SCHEDULE
[Physician grade.] Physician and surgeon grade.
Dentist grade.
NURSE SCHEDULE
Nurse V.
* * * * * * *
CLINICAL [PODIATRIST, CHIROPRACTOR, AND] CHIROPRACTOR AND OPTOMETRIST
SCHEDULE
Chief grade.
* * * * * * *
(c) * * *
(d) [Except] Except for positions described in section
7401(4) of this title and except as provided under subsection
(e), subchapter III, and section 7457 of this title, pay for
positions for which basic pay is paid under this section may
not be paid at a rate in excess of the rate of basic pay
authorized by section 5316 of title 5 for positions in Level V
of the Executive Schedule.
* * * * * * *
[SEC. 7411. FULL-TIME BOARD-CERTIFIED PHYSICIANS AND DENTISTS:
REIMBURSEMENT OF CONTINUING PROFESSIONAL EDUCATION
EXPENSES
[The Secretary shall reimburse any full-time board-
certified physician or dentist appointed under section 7401(1)
of this title for expenses incurred, up to $1,000 per year, for
continuing professional education.]
SEC. 7411. REIMBURSEMENT OF CONTINUING PROFESSIONAL EDUCATION EXPENSES
The Secretary shall reimburse any full-time board-certified
advanced practice registered nurse, physician, or dentist
appointed under section 7401(1) of this title for expenses
incurred, up to $1,000 per year, for continuing professional
education.
* * * * * * *
SEC. 7413. TREATMENT OF PODIATRISTS; CLINICAL OVERSIGHT STANDARDS
(a) Podiatrists.--Except as provided by subsection (b), a
doctor of podiatric medicine who is appointed as a podiatrist
under section 7401(1) of this title is eligible for any
supervisory position in the Veterans Health Administration to
the same degree that a physician appointed under such section
is eligible for the position.
(b) Establishment of Clinical Oversight Standards.--The
Secretary, in consultation with appropriate stakeholders, shall
establish standards to ensure that specialists appointed in the
Veterans Health Administration to supervisory positions do not
provide direct clinical oversight for purposes of peer review
or practice evaluation for providers of other clinical
specialties.
* * * * * * *
Subchapter IV. Pay for Nurses and Other Health-Care Personnel
* * * * * * *
SEC. 7451. NURSES AND OTHER HEALTH-CARE PERSONNEL: COMPETITIVE PAY
(c)(1) * * *
[(2) The maximum rate of basic pay for any grade for a
covered position may not exceed the maximum rate of basic pay
established for positions in level IV of the Executive Schedule
under section 5316 1 of title 5. The maximum rate of basic pay
for a grade for the position of certified registered nurse
anesthetist pursuant to an adjustment under subsection (d) may
exceed the maximum rate otherwise provided in the preceding
sentence.]
(2)(A) The maximum rate of basic pay for any grade for
health-care personnel positions referred to in paragraphs (1)
and (3) of section 7401 of this title (other than the positions
of physician, dentist, and registered nurse) may not exceed the
rate of basic pay established for positions in level IV of the
Executive Schedule under section 5315 of title 5.
(B) Pursuant to an adjustment under subsection (d), the
maximum rate of basic pay for a registered nurse serving as a
nurse executive or a grade for the position of certified
registered nurse anesthetist may exceed the rate of basic pay
established for positions in level IV of the Executive Schedule
under section 5315 of title 5 but may not exceed the rate of
basic pay established for positions in level I of the Executive
Schedule under section 5312 of title 5.
(C) Pursuant to an adjustment under subsection (d), the
maximum rate of basic pay for all registered nurses not
described in subparagraph (B) may exceed the rate of basic pay
established for positions in level IV of the Executive Schedule
under section 5315 of title 5 but may not exceed the rate of
basic pay established for positions in level III of the
Executive Schedule under section 5314 of title 5.
* * * * * * *
SEC. 7454. PHYSICIAN ASSISTANTS AND OTHER HEALTH CARE PROFESSIONALS:
ADDITIONAL PAY
* * * * * * *
(d) In this section, the term ``compensation'' includes all
compensation earned by employees when performing duties
authorized by the Secretary or when the employee is approved to
use annual, sick, family medical, military, or court leave or
during any other paid absence for which pay is not already
regulated.
SEC. 7455. INCREASES IN RATES OF BASIC PAY
* * * * * * *
(c)(1) Subject to paragraph (2), the amount of any increase
under subsection (a) in the minimum rate for any grade may not
(except in the case of nurse anesthetists, licensed practical
nurses, licensed vocational nurses, nursing positions otherwise
covered by title 5, pharmacists, certified clinical
perfusionists, and licensed physical therapists) exceed the
maximum rate of basic pay (excluding any locality-based
comparability payment under section 5304 of title 5 or similar
provision of law) for the grade or level by more than 30
percent.
* * * * * * *
Chapter 76. Health Professionals Educational Assistance Program
* * * * * * *
Subchapter VII. Education Debt Reduction Program
* * * * * * *
SEC. 7683. EDUCATION DEBT REDUCTION
* * * * * * *
(d) Maximum Annual Amount.--(1) The amount of education
debt reduction payments made to or for a participant under the
Education Debt Reduction Program may not exceed [$120,000]
''$240,000 over a total of five years of participation in the
Program, of which not more than [$24,000] $48,000 of such
payments may be made in each year of participation in the
Program.
* * * * * * *
Part VI. Acquisition and Disposition of Property
* * * * * * *
Chapter 81. Acquisition and Operation of Hospital and Domiciliary
Facilities; Procurement and Supply; Enhanced-Use Leases of Real
Property
SUBCHAPTER I. ACQUISITION AND OPERATION OF MEDICAL FACILITIES
Sec.
* * * * * * *
8111A. Furnishing of health-care services to members of the Armed
Forces during a war or national emergency.
8111B. Authority to plan, design, construct, or lease a shared
medical facility.
* * * * * * *
SUBCHAPTER IV. SHARING OF MEDICAL FACILITIES, EQUIPMENT, AND
INFORMATION
* * * * * * *
8159. Authority to pay for services authorized but not subject to
an agreement.
* * * * * * *
Subchapter I. Acquisition and Operation of Medical Facilities
SEC. 8101. DEFINITIONS
For the purposes of this subchapter:
* * * * * * *
(3) The term ``medical facility'' means any facility
or part thereof which is, or will be, under the
jurisdiction of the [Secretary for the provision of
health-care services (including hospital, nursing
home,] Secretary, or as otherwise authorized by law,
for the provision of health-care services (including
hospital, outpatient clinic, nursing home, or
domiciliary care or medical services), including any
necessary building and auxiliary structure, garage,
parking facility, mechanical equipment, trackage
facilities leading thereto, abutting sidewalks,
accommodations for attending personnel, and recreation
facilities associated therewith.
* * * * * * *
SEC. 8104. CONGRESSIONAL APPROVAL OF CERTAIN MEDICAL FACILITY
ACQUISITIONS
(a)(1) * * *
* * * * * * *
[(3) For the purpose of this subsection:
[(A) The term ``major medical facility project''
means a project for the construction, alteration, or
acquisition of a medical facility involving a total
expenditure of more than $10,000,000, but such term
does not include an acquisition by exchange.
[(B) The term ``major medical facility lease'' means
a lease for space for use as a new medical facility at
an average annual rental of more than $1,000,000.]
(3) For purposes of this subsection:
(A) The term ``major medical facility project'' means
a project for the construction, alteration, or
acquisition of a medical facility involving a total
expenditure of more than $20,000,000, but such term
does not include an acquisition by exchange, non-
recurring maintenance projects of the Department, or
the construction, alteration, or acquisition of a
shared Federal medical facility for which the
Department's estimated share of the project costs does
not exceed $20,000,000.
(B) The term ``major medical facility lease'' means a
lease for space for use as a new medical facility at an
average annual rental equal to or greater than the
dollar threshold for leases procured through the
General Services Administration under section
3307(a)(2) of title 40, which shall be subject to
annual adjustment in accordance with section 3307(h) of
such title.
* * * * * * *
SEC. 8111B. AUTHORITY TO PLAN, DESIGN, CONSTRUCT, OR LEASE A SHARED
MEDICAL FACILITY
(a) In General.--(1) The Secretary may enter into
agreements with other Federal agencies for the planning,
designing, constructing, or leasing of shared medical
facilities with the goal of improving access to, and quality
and cost effectiveness of, health care provided by the
Department and other Federal agencies.
(2) Facilities planned, designed, constructed, or leased
under paragraph (1) shall be managed by the Under Secretary for
Health.
(b) Transfer of Amounts to Other Federal Agencies.--(1) The
Secretary may transfer to another Federal agency amounts
appropriated to the Department for ``Construction, Minor
Projects'' for use for the planning, design, or construction of
a shared medical facility if the estimated share of the project
costs to be borne by the Department does not exceed the
threshold for a major medical facility project under section
8104(a)(3)(A) of this title.
(2) The Secretary may transfer to another Federal agency
amounts appropriated to the Department for ``Construction,
Major Projects'' for use for the planning, design, or
construction of a shared medical facility if--
(A) the estimated share of the project costs to be
borne by the Department is more than the threshold for
a major medical facility project under subsection
(a)(3)(A) of section 8104 of this title; and
(B) the requirements for such a project under such
section have been met.
(3) The Secretary may transfer to another Federal agency
amounts appropriated to the applicable appropriations account
of the Department for the purpose of leasing space for a shared
medical facility if the estimated share of the lease costs to
be borne by the Department does not exceed the threshold for a
major medical facility lease under section 8104(a)(3)(B) of
this title.
(c) Transfer of Amounts to Department.--(1) Amounts
transferred to the Department by another Federal agency for the
necessary expenses of planning, designing, or constructing a
shared medical facility for which the estimated share of the
project costs to be borne by the Department does not exceed the
threshold for a major medical facility project under section
8104(a)(3)(A) of this title may be deposited in the
``Construction, Minor Projects'' account of the Department and
used for such necessary expenses.
(2) Amounts transferred to the Department by another
Federal agency for the necessary expenses of planning,
designing, or constructing a shared medical facility for which
the estimated share of the project costs to be borne by the
Department is more than the threshold for a major medical
facility project under section 8104(a)(3)(A) of this title may
be deposited in the ``Construction, Major Projects'' account of
the Department and used for such necessary expenses if the
requirements for such project under section 8104 of this title
have been met.
(3) Amounts transferred to the Department by another
Federal agency for the purpose of leasing space for a shared
medical facility may be credited to the applicable
appropriations account of the Department and shall be available
without fiscal year limitation.
(4) Amounts transferred under paragraphs (1) and (2) shall
be available for the same time period as amounts in the account
to which those amounts are transferred.
* * * * * * *
Subchapter IV. Sharing of Medical Facilities, Equipment, and
Information
* * * * * * *
SEC. 8159. AUTHORITY TO PAY FOR SERVICES AUTHORIZED BUT NOT SUBJECT TO
AN AGREEMENT
(a) In General.--If, in the course of furnishing hospital
care, a medical service, or an extended care service authorized
by the Secretary and pursuant to a contract, agreement, or
other arrangement with the Secretary, a provider who is not a
party to the contract, agreement, or other arrangement
furnishes hospital care, a medical service, or an extended care
service that the Secretary considers necessary, the Secretary
may compensate the provider for the cost of such care or
service.
(b) New Contracts and Agreements.--The Secretary shall take
reasonable efforts to enter into a contract, agreement, or
other arrangement with a provider described in subsection (a)
to ensure that future care and services authorized by the
Secretary and furnished by the provider are subject to such a
contract, agreement, or other arrangement.
* * * * * * *
Subchapter V. Enhanced-Use Leases of Real Property
* * * * * * *
SEC. 8162. ENHANCED-USE LEASES
* * * * * * *
(b)(1) * * *
[(6) The Secretary may not enter into an enhanced-use lease
without certification in advance in writing by the Director of
the Office of Management and Budget that such lease complies
with the requirements of this subchapter.]
(6) The Office of Management and Budget shall review each
enhanced-use lease before the lease goes into effect to
determine whether the lease is in compliance with paragraph
(5).
* * * * * * *
SOCIAL SECURITY ACT
(42 U.S.C. 1395cc(a)(1)(L))
Title 42. The Public Health and Welfare
* * * * * * *
Chapter 7. Social Security
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Subchapter XVIII. Health Insurance for Aged and Disabled
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Part E. Miscellaneous Provisions
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SEC. 1866. AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
(a) * * *
(1) * * *
* * * * * * *
(L) in the case of hospitals which provide
inpatient hospital services for which payment
may be made under this subchapter, to be a
participating provider of medical care [under
section 1703] under chapter 17 of title 38, in
accordance with such admission practices, and
such payment methodology and amounts, as are
prescribed under joint regulations issued by
the Secretary and by the Secretary of Veterans
Affairs in implementation of such section,
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VETERANS' BENEFITS IMPROVEMENTS ACT OF 1994
(Public Law 103-446; 38 U.S.C. 1117 note)
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Title I. Persian Gulf War Veterans
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SEC. 104. DEVELOPMENT OF MEDICAL EVALUATION PROTOCOL.
(a) Uniform Medical Evaluation Protocol.--(1) * * *
* * * * * * *
(4)(A) If the Secretary is unable to diagnose the
symptoms or illness of a veteran provided an
evaluation, or if the symptoms or illness of a veteran
do not respond to treatment provided by the Secretary,
the Secretary may use the authority [in section 1703]
in sections 1703A, 8111, and 8153 of title 38, United
States Code, in order to provide for the veteran to
receive diagnostic tests or treatment at a non-
Department medical facility that may have the
capability of diagnosing or treating the symptoms or
illness of the veteran. The Secretary may provide the
veteran the travel and incidental expenses therefor
pursuant to the provisions of section 111 of title 38,
United States Code.
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CAREGIVERS AND VETERANS OMNIBUS HEALTH SERVICES ACT OF 2010
(Public Law 111-163; 38 U.S.C. 1720G note)
Title I. Caregiver Support
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SEC. 101. ASSISTANCE AND SUPPORT SERVICES FOR CAREGIVERS.
* * * * * * *
(c) Annual Evaluation Report.--
(1) * * *
(2) Contents.--The report required by paragraph (1)
shall include the following:
(A) * * *
* * * * * * *
(iv) an assessment of the
effectiveness and the efficiency of the
implementation of such programs ,
including a description of any barriers
to accessing and receiving care and
services under such programs; and
* * * * * * *
(B) * * *
(i) a description of the outreach
activities carried out by the Secretary
under such program[; and] ;
(ii) an assessment of the manner in
which resources are expended by the
Secretary under such program,
particularly with respect to the
provision of monthly personal caregiver
stipends under paragraph (3)(A)(ii)(v)
of such subsection (a)[.] ; and
(iii) an evaluation of the
sufficiency and consistency of the
training provided to family caregivers
under such program in preparing family
caregivers to provide care to veterans
under such program.
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VETERANS ACCESS, CHOICE, AND ACCOUNTABILITY ACT OF 2014
(Public Law 113-146; 38 U.S.C. 703 note)
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Title VII. Other Veterans Matters
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SEC. 705. LIMITATION ON AWARDS AND BONUSES PAID TO EMPLOYEES OF
DEPARTMENT OF VETERANS AFFAIRS.
(a) Limitation.--The Secretary of Veterans Affairs shall
ensure that the aggregate amount of awards and bonuses paid by
the Secretary in a fiscal year under chapter 45 or 53 of title
5, United States Code, or any other awards or bonuses
authorized under such title or title 38, United States Code,
other than recruitment, relocation, or retention incentives,
does not exceed the following amounts:
* * * * * * *
(Public Law 113-146; 38 U.S.C. 1701 note)
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Title I. Improvement of Access to Care from Non-Department of Veterans
Affairs Providers
SEC. 101. EXPANDED AVAILABILITY OF HOSPITAL CARE AND MEDICAL SERVICES
FOR VETERANS THROUGH THE USE OF AGREEMENTS WITH
NON-DEPARTMENT OF VETERANS AFFAIRS ENTITIES.
* * * * * * *
(p) Authority to Furnish Care and Services.--The Secretary
may not use the authority under this section to furnish care
and services after December 31, 2018.
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Title VIII. Other Matters
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SEC. 802. VETERANS CHOICE FUND.
* * * * * * *
(c) Use of Amounts.--
(1) In general.--Except as provided [by paragraph
(3)] in paragraphs (3) and (4), any amounts deposited
in the Veteran Choice Fund shall be used by the
Secretary of Veterans Affairs to carry out section 101,
including, subject to paragraph (2), any administrative
requirements of such section.
* * * * * * *
(4) Permanent authority for other uses.-Beginning in
fiscal year 2019, amounts remaining in the Veterans
Choice Fund may be used to furnish hospital care,
medical services, and extended care services to
individuals pursuant to chapter 17 of title 38, United
States Code, at non-Department facilities, including
pursuant to non-Department provider programs other than
the program established by section 101. Such amounts
shall be available in addition to amounts available in
other appropriations accounts for such purposes.
(d) Appropriation and Deposit of Amounts.--
(1) In general.--There is authorized to be
appropriated, and is appropriated, to the Secretary of
Veterans Affairs, out of any funds in the Treasury not
otherwise appropriated $10,000,000,000 to be deposited
in the Veterans Choice Fund established by subsection
(a). Such funds shall be available for obligation or
expenditure without fiscal year limitation, and only
for the program created under section 101 (or for
hospital care and medical services pursuant [to
subsection (c)(3)] to paragraphs (3) and (4) of
subsection (c) of this section).
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